Md. Code Regs. 31.10.48.04

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

Section 31.10.48.04 - Noncompliant Contract Terms

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.

Md. Code Regs. 31.10.48.04

Regulation .04 adopted effective 47:6 Md. R. 343, eff. 3/23/2020; amended effective 49:3 Md. R.139, eff. 2/7/2022