Section 15-1628 – Required Disclosures by Pharmacy Benefits Manager; Filing Requirements for Contract or Amendment to Contract
(a) For disputes regarding cost pricing and reimbursement under a participating pharmacy contract, each participating pharmacy contract must include a process to appeal, investigate, and resolve disputes regarding cost pricing and reimbursement that includes: (1) a requirement that an appeal be filed by the contract pharmacy not later than 21 days after: (i) the date a direct or […]
Section 15-1628.1 – Maximum Allowable Cost Pricing Between Pharmacy Benefits Manager and Contracted Pharmacy
(a) (1) In this section the following words have the meanings indicated. (2) “Drug shortage list” means a list of drug products listed on the federal Food and Drug Administration’s Drug Shortages website. (3) (i) “Maximum allowable cost” means the maximum amount that a pharmacy benefits manager or a purchaser will reimburse a contracted pharmacy for the cost of a […]
Section 15-1628.3 – Fee or Performance-Based Reimbursement Related to Claim Adjudication
(a) A pharmacy benefits manager or a carrier may not directly or indirectly charge a contracted pharmacy, or hold a contracted pharmacy responsible for, a fee or performance–based reimbursement related to the adjudication of a claim or an incentive program. (b) A pharmacy benefits manager or carrier may not make or allow any reduction in payment for […]
Section 15-1629 – Audits by Pharmacy Benefits Manager
(a) This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier. (b) This section does not apply to an audit that involves probable or potential fraud or willful misrepresentation by a pharmacy or pharmacist. (c) A pharmacy benefits manager shall conduct an audit of a pharmacy or pharmacist […]
Section 15-1630 – Internal Review Process
(a) This section applies only to a pharmacy benefits manager that provides pharmacy benefits management services on behalf of a carrier. (b) A pharmacy benefits manager shall establish a reasonable internal review process for a pharmacy to request the review of a failure to pay the contractual reimbursement amount of a submitted claim. (c) A pharmacy may request […]
Section 15-1631 – Retroactive Denial or Modification of Reimbursement for Approved Claim
Except for an overpayment as defined in § 15–1629(h) of this subtitle, if a claim has been approved by a pharmacy benefits manager through adjudication, the pharmacy benefits manager may not retroactively deny or modify reimbursement to a pharmacy or pharmacist for the approved claim unless: (1) the claim was fraudulent; (2) the pharmacy or pharmacist had […]
Section 15-1633 – When Request Allowed
A pharmacy benefits manager or its agent may not request a therapeutic interchange unless: (1) the proposed therapeutic interchange is for medical reasons that benefit the beneficiary; or (2) the proposed therapeutic interchange will result in financial savings and benefits to the purchaser or the beneficiary.
Section 15-1634 – Authorization; Disclosures; Money-Saving Claims; Payment for Interchange
(a) Before making a therapeutic interchange, a pharmacy benefits manager or its agent shall obtain authorization from a prescriber or an individual authorized by the prescriber. (b) In any therapeutic interchange solicitation, the following shall be disclosed to the prescriber: (1) that a therapeutic interchange is being solicited; (2) the circumstances under which the originally prescribed drug will be […]
Section 15-1635 – Requirements When Interchange Occurs
If a therapeutic interchange occurs, the pharmacy benefits manager or its agent shall: (1) disclose to the beneficiary, orally or in writing: (i) that the pharmacy benefits manager or its agent requested a therapeutic interchange by contacting the beneficiary’s prescriber; (ii) the prescriber approved the therapeutic interchange; (iii) the names of the originally prescribed drug and the drug dispensed […]
Section 15-1617 – Required Policies, Procedures, and Processes
A pharmacy benefits manager shall ensure that its pharmacy and therapeutics committee has: (1) policies and procedures, including disclosure requirements, to address potential conflicts of interest that members of the pharmacy and therapeutics committee may have with developers or manufacturers of prescription drugs; (2) a process to evaluate medical and scientific evidence concerning the safety and effectiveness […]