Md. Code Regs. 31.10.47.05

Current through Register Vol. 51, No. 22, November 1, 2024

Section 31.10.47.05 - Complaint Process

A. Prior to filing a complaint with the Commissioner, a contracted pharmacy or its designee shall exhaust the internal appeal process established in the participating pharmacy contract.

B. A contracted pharmacy or its designee may file a complaint with the Commissioner to dispute a PBM's appeal decision for the following reasons:

(1) The PBM's cost pricing did not comply with Insurance Article, Title 15, Subtitle 16, Annotated Code of Maryland; or

(2) The PBM's cost pricing or reimbursement amount determination did not meet the terms of the applicable participating pharmacy contract.

C. A complaint is properly completed and may be filed if a contracted pharmacy or its designee:

(1) Completes all applicable portions of the Commissioner's complaint form;

(2) Provides a copy of the relevant contract or the provisions that are related to the appeal, including but not limited to establishing a drug pricing or pharmacy reimbursement amount, sources, pricing information, and the compensation program of the applicable participating pharmacy contract; and

(3) Provides a copy of the appeal decision.

D. A complaint may not include more than ten appeal decisions using a single complaint form.

E. Notification of the Complaint to the PBM.

(1) Upon receipt of a completed complaint form, the Commissioner shall provide a copy of the submitted complaint form to the PBM.

(2) Within 5 working days of receiving the Commissioner's notice, the PBM shall provide the Commissioner:

(a) A complete, unredacted copy of the applicable portion of the participating pharmacy contract relating to the compensation program and the complaint filed with the Commissioner, including any other contract under which the pricing or reimbursement amount is determined;

(b) A copy of the applicable source and pricing information used to calculate the pharmacy reimbursement amount;

(c) A mathematical calculation that demonstrates how the reimbursement amount was determined;

(d) All information required to complete the response portion of the complaint form; and

(e) Any other information the Commissioner may require for the purposes of determining a PBM's compliance with:

(i) Insurance Article, Annotated Code of Maryland;

(ii) This chapter;

(iii) The compensation program; or

(iv) The applicable terms of the participating pharmacy contract.

Md. Code Regs. 31.10.47.05

Regulation .05 adopted effective 47:6 Md. R. 343, eff. 3/23/2020