A. A PBM may have a contract form or amendment to a contract form disapproved at any time after the contract form or amendment to a contract form has been submitted as part of an informational filing if the contract form or amendment form contains or uses any language that:
- (1) Violates Insurance Article, Title 15, Subtitle 16, Annotated Code of Maryland, or any applicable statutory provisions, including but not limited to Insurance Article, §§15-112, 15-112.2(a)—(e), 15-123(d), 15-1004, 15-1005, 15-1008(c), 15-1009, 15-1628—15-1628.3, 15-1629, 15-1631, and 15-1633—15-1639, and Health-General Article, §§19-710(s) and (t) and 19-712.2, Annotated Code of Maryland;
- (2) Does not disclose the components of the compensation program through which a reimbursement rate is set;
- (3) Includes a definition of “multisource generic drug” that is inconsistent with COMAR 31.10.46, or “generic” or “brand name drug” that is inconsistent with Health Occupations Article, §12-504, Annotated Code of Maryland;
- (4) Allows the PBM to reimburse a covered drug in an amount that differs, including zero, based on the identity of the wholesale distributor used by a contracting pharmacy for acquisition of the covered drug;
- (5) Except for instances of error or fraud, allows the PBM to reclassify, recategorize, or recharacterize an adjudicated claim;
- (6) In any way prohibits or restricts a pharmacist or pharmacy from filing a complaint with the Commissioner; or
- (7) Fails to include the internal appeal provisions in the contract.
- B. No provisions in Insurance Article, Annotated Code of Maryland, or this chapter may be waived or modified by contract.
Authority: Insurance Article, §§2-109, 12-203(d)(2), 15-1628, and 15-1642, Annotated Code of Maryland
Effective date: Effective March 23, 2020 (47:6 Md. R. 343)
Regulation .02B amended effective February 7, 2022 (49:3 Md. R. 141)
Regulation .03 amended effective February 7, 2022 (49:3 Md. R. 141)
Regulation .04A amended effective February 7, 2022 (49:3 Md. R. 141)
Regulation .05A amended effective February 7, 2022 (49:3 Md. R. 141)