Md. Code Regs. 31.10.50.04

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

Section 31.10.50.04 - Noncompliant Contract Terms

A. A PSAO may have a contract form or amendment to a contract form disapproved if the contract or amendment contains or uses any language that:

(1) Violates Title 15, Subtitle 16 or Subtitle 20 of the Insurance Article, Annotated Code of Maryland or any applicable statutory provisions, including but not limited to Insurance Article, §§ 15-1611, 15-1628, 15-1628.1, 15-1628.2, 15-1628.3, 15-1629, 15-1631, 15-1633, 15-1634-151639, 15-2011, 15-2013(c), 15-2015, and 15-2016, Annotated Code of Maryland;

(2) Includes a definition of "multisource generic drug" that is inconsistent with COMAR 31.46, or "generic" or "brand name drug" that is inconsistent with Health Occupations Article, § 12-504, Annotated Code of Maryland;

(3) 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;

(4) Except for instances of error or fraud, allows a PBM or PSAO to re-classify, re-categorize, or re-characterize an adjudicated claim;

(5) In any way prohibits or restricts a pharmacist or pharmacy from filing a complaint with the Commissioner; and

(6) Fails to include the internal appeal provisions in the contract.

B. No provisions in the Insurance Article, Annotated Code of Maryland or this chapter may be waived or modified by contract.

Md. Code Regs. 31.10.50.04

Regulation .04 adopted effective 49:26 Md. R. 1081, eff. 12/26/2022