US Lawyer Database

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 […]