EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
*hb1006*
HOUSE BILL 1006
J5 2lr1851
By: Delegate Kipke
Introduced and read first time: February 10, 2022
Assigned to: Health and Government Operations
A BILL ENTITLED
AN ACT concerning 1
Pharmacy Benefits Managers – Network Adequacy, Credentialing, and 2
Reimbursement 3
FOR the purpose of requiring a pharmacy benefits manager or purchaser to maintain a 4
reasonably adequate and accessible network of pharmacies; prohibiting a pharmacy 5
benefits manager or purchaser from requiring a pharmacy or pharmacist to obtain 6
or maintain certain accreditation, certification, or credentialing as a condition for 7
participating in the pharmacy benefits manager’s or purchaser’s network; altering 8
certain reimbursement requirements for pharmacy benefits managers and 9
purchasers; authorizing a pharmacy or pharmacist to decline to dispense a 10
prescription drug or provide a pharmacy service if reimbursement will be less than 11
the pharmacy acquisition cost; and generally relating to pharmacy benefits 12
managers. 13
BY adding to 14
Article – Insurance 15
Section 15–1611.2 16
Annotated Code of Maryland 17
(2017 Replacement Volume and 2021 Supplement) 18
BY repealing and reenacting, with amendments, 19
Article – Insurance 20
Section 15–1628 and 15–1628.3 21
Annotated Code of Maryland 22
(2017 Replacement Volume and 2021 Supplement) 23
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 24
That the Laws of Maryland read as follows: 25
Article – Insurance 26
2 HOUSE BILL 1006
15–1611.2. 1
(A) SUBJECT TO SUBSECTION (B) OF THIS SECTION, A PHARMACY BENEFITS 2
MANAGER OR PURCHASER SHALL MAINTAIN A REA SONABLY ADEQUATE AND 3
ACCESSIBLE PHARMACY BENEFITS MANAGER OR PURCHASER NETWORK 4
CONSISTING OF CONTRA CTED PHARMACIES THAT PROVIDE CONVENI ENT PATIENT 5
ACCESS TO PHARMACY S ERVICES. 6
(B) (1) THE COMMISSIONER SHALL ES TABLISH CRITERIA FOR 7
DETERMINING THE ADEQUACY OF A PH ARMACY BENEFITS MANA GER’S OR 8
PURCHASER ’S NETWORK THAT INCLUDE S: 9
(I) A DETERMINATION OF T HE PURCHASERS THAT C ONTRACT 10
WITH THE PHARMACY BENEFITS MANAGER AND GEOGRAPH IC LOCATION IN WHICH 11
THE PURCHASERS OFFER COVERAGE FOR PRESCRI PTION DRUG BENEFITS ; 12
(II) A CALCULATION FOR DE TERMINING THE REASONABLE 13
DISTANCE FROM A PATI ENT’S HOME TO A CONTRACTED PHAR MACY; AND 14
(III) A REVIEW OF COMPENSATION PROG RAMS TO ENSURE THAT 15
THE REIMBURSEMENT PA ID TO PHARMACIES AND PHARMACISTS FOR PHAR MACY 16
SERVICES IS FAIR AND REASONABLE . 17
(2) A MAIL ORDER PHARMACY MAY NOT BE INCLUDED IN A 18
DETERMINATION OF A P HARMACY BENEFITS MAN AGER’S OR PURCHASER ’S 19
NETWORK ADEQUACY . 20
(C) THE COMMISSIONER MAY ADOP T REGULATIONS TO CAR RY OUT THIS 21
SECTION. 22
15–1628. 23
(a) (1) At the time of entering into a contract with a pharmacy or a pharmacist, 24
and at least 30 working days before any contract change, a pharmacy benefits manager 25
shall disclose to the pharmacy or pharmacist: 26
(i) the applicable terms, conditions, and reimbursement rates; 27
(ii) the process and procedures for verifying pharmacy benefits and 28
beneficiary eligibility; 29
(iii) the dispute resolution and audit appeals process; and 30
HOUSE BILL 1006 3
(iv) the process and procedures for verifying the prescription drugs 1
included on the formularies used by the pharmacy benefits manager. 2
(2) (i) This paragraph does not apply to a requirement that a specialty 3
pharmacy obtain national certification to be considered a specialty pharmacy in a pharmacy 4
benefits manager’s or [carrier’s] PURCHASER ’S network. 5
(ii) For purposes of credentialing a pharmacy or a pharmacist as a 6
condition for participating in a pharmacy benefits manager’s OR PURCHASER ’S network 7
[for a carrier], the pharmacy benefits manager OR PURCHASER may not: 8
1. require a pharmacy or pharmacist to: 9
A. renew credentialing more frequently than once every 3 10
years; or 11
B. OBTAIN OR MAINTAIN ACCREDITATION , 12
CERTIFICATION , OR CREDENTIALING THA T IS INCONSISTENT WI TH, MORE 13
STRINGENT THAN , OR IN ADDITION TO STATE REQUIREMENTS FO R LICENSURE OR 14
RELEVANT FEDERAL OR STATE STANDARDS ; OR 15
2. charge a pharmacy or pharmacist a fee for the initial 16
credentialing or renewing credentialing. 17
(b) (1) Each contract form or an amendment to a contract form between a 18
pharmacy benefits manager and a pharmacy may not become effective unless at least 30 19
days before the contract form or amendment to the contract form is to become effective, the 20
pharmacy benefits manager files an informational filing with the Commissioner in the 21
manner required by the Commissioner that includes a copy of the contract form or 22
amendment to the contract form. 23
(2) The Commissioner is not required to review the informational filing to 24
evaluate whether a contract form or amendment to a contract form is in violation of this 25
subtitle at the time the informational filing is made. 26
(3) The Commissioner may review and disapprove a cont ract form or 27
amendment to a contract form at any time after the contract form or amendment to the 28
contract form has been submitted as part of an informational filing. 29
(C) THE COMMISSIONER MAY USE A CONTRACT FILED UND ER SUBSECTION 30
(B) OF THIS SECTION IN M AKING A DETERMINATIO N OF WHETHER A PHARMAC Y 31
BENEFITS MANAGER ’S OR PURCHASER ’S NETWORK IS ADEQUATE AS REQUIRED 32
UNDER § 15–1611.2 OF THIS SUBTITLE. 33
15–1628.3. 34
4 HOUSE BILL 1006
(a) A pharmacy benefits manager or a [carrier] PURCHASER may not directly or 1
indirectly charge a contracted pharmacy, or hold a contracted pharmacy responsible for, a 2
fee or performance–based reimbursement related to the adjudication of a claim or an 3
incentive program THAT IS NOT SPECIFIC ALLY ENUMERATED BY T HE PHARMACY 4
BENEFITS MANAGER OR PURCHASER AT THE TIM E OF CLAIM PROCESSING . 5
(b) A pharmacy benefits manager or [carrier] PURCHASER may not make or 6
allow any reduction in payment for pharmacy services by a pharmacy benefits manager or 7
[carrier] PURCHASER or directly or indirectly reduce a payment for a pharmacy service 8
under a reconciliation process to an effective rate of reimbursement, including generic 9
effective rates, brand effective rates, direct and indirect remuneration fees, or any other 10
reduction or aggregate reduction of payments. 11
(C) IF THE AMOUNT REIMBUR SED BY A PHARMACY BE NEFITS MANAGER OR 12
PURCHASER FOR A PRESCRIPTION D RUG OR PHARMACY SERV ICE IS LESS THAN THE 13
PHARMACY ACQUISITION COST FOR THE SAME PR ESCRIPTION DRUG OR PHARM ACY 14
SERVICE, THE PHARMACY OR PHAR MACIST MAY DECLINE T O DISPENSE THE 15
PRESCRIPTION DRUG OR PROVIDE THE PHARMACY SERVICE TO A BENEFIC IARY. 16
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all 17
policies, contracts, and health benefit plans issued, delivered, or renewed in the State on or 18
after January 1, 2023. 19
SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect 20
January 1, 2023. 21