Maryland 2022 Regular Session

Maryland House Bill HB1014 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1
2	2
3	3	EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTING LAW.
4	4	[Brackets] indicate matter deleted from existing law.
5	5	hb1014
6	6
7	7	HOUSE BILL 1014
8	8	C3 2lr0521
9	9	CF SB 690
10	10	By: Delegates Kipke, Krebs, Morgan, and Saab
11	11	Introduced and read first time: February 10, 2022
12	12	Assigned to: Health and Government Operations
13	13
14	14	A BILL ENTITLED
15	15
16	16	AN ACT concerning 1
17	17
18	18	Pharmacy Benefits Managers – Definitions of Carrier, ERISA, and Purchaser 2
19	19
20	20	FOR the purpose of repealing the definitions of “carrier” and “ERISA” and altering the 3
21	21	definition of “purchaser” for the purpose of applying certain provisions of State 4
22	22	insurance law governing pharmacy benefits managers to certain persons that 5
23	23	provide prescription drug coverage or benefits in the State through plans or 6
24	24	programs subject to the federal Employee Retirement Income Security Act of 1974 7
25	25	(ERISA); repealing a certain provision that restricts applicability of certain 8
26	26	provisions of law to pharmacy benefits managers that provide pharmacy benefits 9
27	27	management services on behalf of a carrier; and generally relating to pharmacy 10
28	28	benefits managers. 11
29	29
30	30	BY repealing and reenacting, with amendments, 12
31	31	Article – Insurance 13
32	32	Section 15–1601, 15–1606, 15–1611, 15–1611.1, 15–1612, 15–1613, 15–1622, 14
33	33	15–1628(a), 15–1628.3, 15–1629, 15–1630, and 15–1633.1 15
34	34	Annotated Code of Maryland 16
35	35	(2017 Replacement Volume and 2021 Supplement) 17
36	36
37	37	BY repealing 18
38	38	Article – Insurance 19
39	39	Section 15–1633 20
40	40	Annotated Code of Maryland 21
41	41	(2017 Replacement Volume and 2021 Supplement) 22
42	42
43	43	SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 23
44	44	That the Laws of Maryland read as follows: 24
45	45
46	46	Article – Insurance 25
47	47
48	48	15–1601. 26 2 HOUSE BILL 1014
49	49
50	50
51	51
52	52	(a) In this subtitle the following words have the meanings indicated. 1
53	53
54	54	(b) “Agent” means a pharmacy, a pharmacist, a mail order pharmacy, or a 2
55	55	nonresident pharmacy acting on behalf or at the direction of a pharmacy benefits manager. 3
56	56
57	57	(c) “Beneficiary” means an individual who receives prescription drug coverage or 4
58	58	benefits from a purchaser. 5
59	59
60	60	(d) [(1) “Carrier” means the State Employee and Retiree Health and Welfare 6
61	61	Benefits Program, an insurer, a nonprofit health service plan, or a health maintenance 7
62	62	organization that: 8
63	63
64	64	(i) provides prescription drug coverage or benefits in the State; and 9
65	65
66	66	(ii) enters into an agreement with a pharmacy benefits manager for 10
67	67	the provision of pharmacy benefits management services. 11
68	68
69	69	(2) “Carrier” does not include a person that provides prescription drug 12
70	70	coverage or benefits through plans subject to ERISA and does not provide prescription drug 13
71	71	coverage or benefits through insurance, unless the person is a multiple employer welfare 14
72	72	arrangement as defined in § 514(b)(6)(a)(ii) of ERISA. 15
73	73
74	74	(e)] “Compensation program” means a program, policy, or process through which 16
75	75	sources and pricing information are used by a pharmacy benefits manager to determine the 17
76	76	terms of payment as stated in a participating pharmacy contract. 18
77	77
78	78	[(f)] (E) “Contracted pharmacy” means a pharmacy that participates in the 19
79	79	network of a pharmacy benefits manager through a contract with: 20
80	80
81	81	(1) the pharmacy benefits manager; or 21
82	82
83	83	(2) a pharmacy services administration organization or a group purchasing 22
84	84	organization. 23
85	85
86	86	[(g) “ERISA” has the meaning stated in § 8–301 of this article.] 24
87	87
88	88	[(h)] (F) “Formulary” means a list of prescription drugs used by a purchaser. 25
89	89
90	90	[(i)] (G) (1) “Manufacturer payments” means any compensation or 26
91	91	remuneration a pharmacy benefits manager receives from or on behalf of a pharmaceutical 27
92	92	manufacturer. 28
93	93
94	94	(2) “Manufacturer payments” includes: 29
95	95
96	96	(i) payments received in accordance with agr eements with 30 HOUSE BILL 1014 3
97	97
98	98
99	99	pharmaceutical manufacturers for formulary placement and, if applicable, drug utilization; 1
100	100
101	101	(ii) rebates, regardless of how categorized; 2
102	102
103	103	(iii) market share incentives; 3
104	104
105	105	(iv) commissions; 4
106	106
107	107	(v) fees under products and services agreements; 5
108	108
109	109	(vi) any fees received for the sale of utilization data to a 6
110	110	pharmaceutical manufacturer; and 7
111	111
112	112	(vii) administrative or management fees. 8
113	113
114	114	(3) “Manufacturer payments” does not include purchase discounts based on 9
115	115	invoiced purchase terms. 10
116	116
117	117	[(j)] (H) “Nonprofit health maintenance organization” has the meaning stated 11
118	118	in § 6–121(a) of this article. 12
119	119
120	120	[(k)] (I) “Nonresident pharmacy” has the meaning stated in § 12–403 of the 13
121	121	Health Occupations Article. 14
122	122
123	123	[(l)] (J) “Participating pharmacy contract” means a contract filed with the 15
124	124	Commissioner in accordance with § 15–1628(b) of this subtitle. 16
125	125
126	126	[(m)] (K) “Pharmacist” has the meaning stated in § 12–101 of the Health 17
127	127	Occupations Article. 18
128	128
129	129	[(n)] (L) “Pharmacy” has the meaning stated in § 12 –101 of the Health 19
130	130	Occupations Article. 20
131	131
132	132	[(o)] (M) “Pharmacy and therapeutics committee” means a committee 21
133	133	established by a pharmacy benefits manager to: 22
134	134
135	135	(1) objectively appraise and evaluate prescription drugs; and 23
136	136
137	137	(2) make recommendations to a purchaser regarding the selection of drugs 24
138	138	for the purchaser’s formulary. 25
139	139
140	140	[(p)] (N) (1) “Pharmacy benefits management services” means: 26
141	141
142	142	(i) the procurement of prescription drugs at a negotiated rate for 27
143	143	dispensation within the State to beneficiaries; 28
144	144	4 HOUSE BILL 1014
145	145
146	146
147	147	(ii) the administration or management of prescription drug coverage 1
148	148	provided by a purchaser for beneficiaries; and 2
149	149
150	150	(iii) any of the following services provided with regard to the 3
151	151	administration of prescription drug coverage: 4
152	152
153	153	1. mail service pharmacy; 5
154	154
155	155	2. claims processing, retail network management, and 6
156	156	payment of claims to pharmacies for prescription drugs dispensed to beneficiaries; 7
157	157
158	158	3. clinical formulary development and management services; 8
159	159
160	160	4. rebate contracting and administration; 9
161	161
162	162	5. patient compliance, therapeutic intervention, and generic 10
163	163	substitution programs; or 11
164	164
165	165	6. disease management programs. 12
166	166
167	167	(2) “Pharmacy benefits management services” does not include any service 13
168	168	provided by a nonprofit health maintenance organization that operates as a group model, 14
169	169	provided that the service: 15
170	170
171	171	(i) is provided solely to a member of the nonprofit health 16
172	172	maintenance organization; and 17
173	173
174	174	(ii) is furnished through the internal pharmacy operations of the 18
175	175	nonprofit health maintenance organization. 19
176	176
177	177	[(q)] (O) “Pharmacy benefits manager” means a person that performs pharmacy 20
178	178	benefits management services. 21
179	179
180	180	[(r)] (P) “Proprietary information” means: 22
181	181
182	182	(1) a trade secret; 23
183	183
184	184	(2) confidential commercial information; or 24
185	185
186	186	(3) confidential financial information. 25
187	187
188	188	[(s)] (Q) “Purchaser” means a person that offers a plan or program in the State, 26
189	189	including the State Employee and Retiree Health and Welfare Benefits Program, AN 27
190	190	INSURER, A NONPROFIT HEALTH S ERVICE PLAN , OR A HEALTH MAINTENA NCE 28
191	191	ORGANIZATION, that: 29
192	192	HOUSE BILL 1014 5
193	193
194	194
195	195	(1) provides prescription drug coverage or benefits in the State; and 1
196	196
197	197	(2) enters into an agreement with a pharmacy benefits manager for 2
198	198	the provision of pharmacy benefits management services. 3
199	199
200	200	[(t)] (R) “Rebate sharing contract” means a contract between a pharmacy 4
201	201	benefits manager and a purchaser under which the pharmacy benefits manager agrees to 5
202	202	share manufacturer payments with the purchaser. 6
203	203
204	204	[(u)] (S) (1) “Therapeutic interchange” means any change from one 7
205	205	prescription drug to another. 8
206	206
207	207	(2) “Therapeutic interchange” does not include: 9
208	208
209	209	(i) a change initiated pursuant to a drug utilization review; 10
210	210
211	211	(ii) a change initiated for patient safety reasons; 11
212	212
213	213	(iii) a change required due to market unavailability of the currently 12
214	214	prescribed drug; 13
215	215
216	216	(iv) a change from a brand name drug to a generic drug in accordance 14
217	217	with § 12–504 of the Health Occupations Article; or 15
218	218
219	219	(v) a change required for coverage reasons because the originally 16
220	220	prescribed drug is not covered by the beneficiary’s formulary or plan. 17
221	221
222	222	[(v)] (T) “Therapeutic interchange solicitation” means any communication by a 18
223	223	pharmacy benefits manager for the purpose of requesting a therapeutic interchange. 19
224	224
225	225	[(w)] (U) “Trade secret” has the meaning stated in § 11–1201 of the Commercial 20
226	226	Law Article. 21
227	227
228	228	15–1606. 22
229	229
230	230	A [carrier] PURCHASER may not enter into an agreement with a pharmacy benefits 23
231	231	manager that has not registered with the Commissioner. 24
232	232
233	233	15–1611. 25
234	234
235	235	(a) [This section applies only to a pharmacy benefits manager that provides 26
236	236	pharmacy benefits management services on behalf of a carrier. 27
237	237
238	238	(b)] A pharmacy benefits manager may not prohibit a pharmacy or pharmacist 28
239	239	from: 29
240	240	6 HOUSE BILL 1014
241	241
242	242
243	243	(1) providing a beneficiary with information regarding the retail price for 1
244	244	a prescription drug or the amount of the cost share for which the beneficiary is responsible 2
245	245	for a prescription drug; 3
246	246
247	247	(2) discussing with a beneficiary information regarding the retail price for 4
248	248	a prescription drug or the amount of the cost share for which the beneficiary is responsible 5
249	249	for a prescription drug; or 6
250	250
251	251	(3) if a more affordable drug is available than one on the purchaser’s 7
252	252	formulary and the requirements for a therapeutic interchange under §§ [15–1633.1] 8
253	253	15–1633 through 15–1639 of this subtitle are met, selling the more affordable alternative 9
254	254	to the beneficiary. 10
255	255
256	256	[(c)] (B) This section may not be construed to alter the requirements for a 11
257	257	therapeutic interchange under §§ [15–1633.1] 15–1633 through 15–1639 of this subtitle. 12
258	258
259	259	15–1611.1. 13
260	260
261	261	(a) [This section applies only to a pharmacy benefits manager that provides 14
262	262	pharmacy benefits management services on behalf of a carrier. 15
263	263
264	264	(b)] Except as provided in subsection [(c)] (B) of this section, a pharmacy benefits 16
265	265	manager may not require that a beneficiary use a specific pharmacy or entity to fill a 17
266	266	prescription if: 18
267	267
268	268	(1) the pharmacy benefits manager or a corporate affiliate of the pharmacy 19
269	269	benefits manager has an ownership interest in the pharmacy or entity; or 20
270	270
271	271	(2) the pharmacy or entity has an ownership interest in the pharmacy 21
272	272	benefits manager or a corporate affiliate of the pharmacy benefits manager. 22
273	273
274	274	[(c)] (B) A pharmacy benefits manager may require a beneficiary to use a 23
275	275	specific pharmacy or entity for a specialty drug as defined in § 15–847 of this title. 24
276	276
277	277	15–1612. 25
278	278
279	279	(a) [This section applies only to a pharmacy benefits manager that provides 26
280	280	pharmacy benefits management services on behalf of a carrier. 27
281	281
282	282	(b)] This section does not apply to reimbursement: 28
283	283
284	284	(1) for specialty drugs; 29
285	285
286	286	(2) for mail order drugs; or 30
287	287
288	288	(3) to a chain pharmacy with more than 15 stores or a pharmacist who is 31 HOUSE BILL 1014 7
289	289
290	290
291	291	an employee of the chain pharmacy. 1
292	292
293	293	[(c)] (B) A pharmacy benefits manager may not reimburse a pharmacy or 2
294	294	pharmacist for a pharmaceutical product or pharmacist service in an amount less than the 3
295	295	amount that the pharmacy benefits manager reimburses itself or an affiliate for providing 4
296	296	the same product or service. 5
297	297
298	298	15–1613. 6
299	299
300	300	A pharmacy and therapeutics committee established by a pharmacy benefits 7
301	301	manager performing pharmacy benefits management services [on behalf of a carrier] shall 8
302	302	meet the requirements of this part. 9
303	303
304	304	15–1622. 10
305	305
306	306	[(a) Except as provided for in subsection (b) of this section, the provisions of §§ 11
307	307	15–1623 and 15–1624 of this subtitle apply only to a pharmacy benefits manager that 12
308	308	provides pharmacy benefits management services on behalf of a carrier. 13
309	309
310	310	(b)] The provisions of §§ 15–1623 and 15–1624 of this part do not apply to a 14
311	311	pharmacy benefits manager when providing pharmacy benefits management services to a 15
312	312	purchaser that is affiliated with the pharmacy benefits manager through common 16
313	313	ownership within an insurance holding company. 17
314	314
315	315	15–1628. 18
316	316
317	317	(a) (1) At the time of entering into a contract with a pharmacy or a pharmacist, 19
318	318	and at least 30 working days before any contract change, a pharmacy benefits manager 20
319	319	shall disclose to the pharmacy or pharmacist: 21
320	320
321	321	(i) the applicable terms, conditions, and reimbursement rates; 22
322	322
323	323	(ii) the process and procedures for verifying pharmacy benefits and 23
324	324	beneficiary eligibility; 24
325	325
326	326	(iii) the dispute resolution and audit appeals process; and 25
327	327
328	328	(iv) the process and procedures for verifying the prescription drugs 26
329	329	included on the formularies used by the pharmacy benefits manager. 27
330	330
331	331	(2) (i) This paragraph does not apply to a requirement that a specialty 28
332	332	pharmacy obtain national certification to be considered a specialty pharmacy in a pharmacy 29
333	333	benefits manager’s or [carrier’s] PURCHASER’S network. 30
334	334
335	335	(ii) For purposes of credentialing a pharmacy or a pharmacist as a 31
336	336	condition for participating in a pharmacy benefits manager’s OR PURCHASER ’S network 32 8 HOUSE BILL 1014
337	337
338	338
339	339	[for a carrier], the pharmacy benefits manager OR PURCHASE R may not: 1
340	340
341	341	1. require a pharmacy or pharmacist to renew credentialing 2
342	342	more frequently than once every 3 years; or 3
343	343
344	344	2. charge a pharmacy or pharmacist a fee for the initial 4
345	345	credentialing or renewing credentialing. 5
346	346
347	347	15–1628.3. 6
348	348
349	349	(a) A pharmacy benefits manager or a [carrier] PURCHASER may not directly or 7
350	350	indirectly charge a contracted pharmacy, or hold a contracted pharmacy responsible for, a 8
351	351	fee or performance–based reimbursement related to the adjudication of a claim or an 9
352	352	incentive program. 10
353	353
354	354	(b) A pharmacy benefits manager or [carrier] PURCHASER may not make or 11
355	355	allow any reduction in payment for pharmacy services by a pharmacy benefits manager or 12
356	356	[carrier] PURCHASER or directly or indirectly reduce a payment for a pharmacy service 13
357	357	under a reconciliation process to an effective rate of reimbursement, including generic 14
358	358	effective rates, brand effective rates, direct and indirect remuneration fees, or any other 15
359	359	reduction or aggregate reduction of payments. 16
360	360
361	361	15–1629. 17
362	362
363	363	(a) [This section applies only to a pharmacy benefits manager that provides 18
364	364	pharmacy benefits management services on behalf of a carrier. 19
365	365
366	366	(b)] This section does not apply to an audit that involves probable or potential 20
367	367	fraud or willful misrepresentation by a pharmacy or pharmacist. 21
368	368
369	369	[(c)] (B) A pharmacy benefits manager shall conduct an audit of a pharmacy or 22
370	370	pharmacist under contract with the pharmacy benefits manager in accordance with this 23
371	371	section. 24
372	372
373	373	[(d)] (C) A pharmacy benefits manager may not schedule an onsite audit to begin 25
374	374	during the first 5 calendar days of a month unless requested by the pharmacy or 26
375	375	pharmacist. 27
376	376
377	377	[(e)] (D) When conducting an audit, a pharmacy benefits manager shall: 28
378	378
379	379	(1) if the audit is onsite, provide written notice to the pharmacy or 29
380	380	pharmacist at least 2 weeks before conducting the initial onsite audit for each audit cycle; 30
381	381
382	382	(2) employ the services of a pharmacist if the audit requires the clinical or 31
383	383	professional judgment of a pharmacist; 32
384	384	HOUSE BILL 1014 9
385	385
386	386
387	387	(3) permit its auditors to enter the prescription area of a pharmacy only 1
388	388	when accompanied by or authorized by a member of the pharmacy staff; 2
389	389
390	390	(4) allow a pharmacist or pharmacy to use any prescription, or authorized 3
391	391	change to a prescription, that meets the requirements of COMAR 10.34.20.02 to validate 4
392	392	claims submitted for reimbursement for dispensing of original and refill prescriptions; 5
393	393
394	394	(5) for purposes of validating the pharmacy record with respect to orders 6
395	395	or refills of a drug, allow the pharmacy or pharmacist to use records of a hospital or a 7
396	396	physician or other prescriber authorized by law that are: 8
397	397
398	398	(i) written; or 9
399	399
400	400	(ii) transmitted electronically or by any other means of 10
401	401	communication authorized by contract between the pharmacy and the pharmacy benefits 11
402	402	manager; 12
403	403
404	404	(6) audit each pharmacy and pharmacist under the same standards and 13
405	405	parameters as other similarly situated pharmacies or pharmacists audited by the 14
406	406	pharmacy benefits manager; 15
407	407
408	408	(7) only audit claims submitted or adjudicated within the 2–year period 16
409	409	immediately preceding the audit, unless a longer period is authorized under federal or State 17
410	410	law; 18
411	411
412	412	(8) deliver the preliminary audit report to the pharmacy or pharmacist 19
413	413	within 120 calendar days after the completion of the audit, with reasonable extensions 20
414	414	allowed; 21
415	415
416	416	(9) in accordance with subsection [(k)] (J) of this section, allow a pharmacy 22
417	417	or pharmacist to produce documentation to address any discrepancy found during the audit; 23
418	418	and 24
419	419
420	420	(10) deliver the final audit report to the pharmacy or pharmacist: 25
421	421
422	422	(i) within 6 months after delivery of the preliminary audit report if 26
423	423	the pharmacy or pharmacist does not request an internal appeal under subsection [(k)] (J) 27
424	424	of this section; or 28
425	425
426	426	(ii) within 30 days after the conclusion of the internal appeals 29
427	427	process under subsection [(k)] (J) of this section if the pharmacy or pharmacist requests 30
428	428	an internal appeal. 31
429	429
430	430	[(f)] (E) If a contract between a pharmacy or pharmacist and a pharmacy 32
431	431	benefits manager specifies a period of time in which a pharmacy or pharmacist is allowed 33
432	432	to withdraw and resubmit a claim and that period of time expires before the pharmacy 34
433	433	benefits manager delivers a preliminary audit report that identifies discrepancies, the 35 10 HOUSE BILL 1014
434	434
435	435
436	436	pharmacy benefits manager shall allow the pharmacy or pharmacist to withdraw and 1
437	437	resubmit a claim within 30 days after: 2
438	438
439	439	(1) the preliminary audit report is delivered if the pharmacy or pharmacist 3
440	440	does not request an internal appeal under subsection [(k)] (J) of this section; or 4
441	441
442	442	(2) the conclusion of the internal appeals process under subsection [(k)] (J) 5
443	443	of this section if the pharmacy or pharmacist requests an internal appeal. 6
444	444
445	445	[(g)] (F) During an audit, a pharmacy benefits manager may not disrupt the 7
446	446	provision of services to the customers of a pharmacy. 8
447	447
448	448	[(h)] (G) (1) A pharmacy benefits manager may not: 9
449	449
450	450	(i) use the accounting practice of extrapolation to calculate 10
451	451	overpayments or underpayments; or 11
452	452
453	453	(ii) Except as provided in paragraph (2) of this subsection: 12
454	454
455	455	1. share information from an audit with another pharmacy 13
456	456	benefits manager; or 14
457	457
458	458	2. use information from an audit conducted by another 15
459	459	pharmacy benefits manager. 16
460	460
461	461	(2) Paragraph (1)(ii) of this subsection does not apply to the sharing of 17
462	462	information: 18
463	463
464	464	(i) required by federal or State law; 19
465	465
466	466	(ii) in connection with an acquisition or merger involving the 20
467	467	pharmacy benefits manager; or 21
468	468
469	469	(iii) at the payor’s request or under the terms of the agreement 22
470	470	between the pharmacy benefits manager and the payor. 23
471	471
472	472	[(i)] (H) The recoupment of a claims payment from a pharmacy or pharmacist 24
473	473	by a pharmacy benefits manager shall be based on an actual overpayment or denial of an 25
474	474	audited claim unless the projected overpayment or denial is part of a settlement agreed to 26
475	475	by the pharmacy or pharmacist. 27
476	476
477	477	[(j)] (I) (1) In this subsection, “overpayment” means a payment by the 28
478	478	pharmacy benefits manager to a pharmacy or pharmacist that is greater than the rate or 29
479	479	terms specified in the contract between the pharmacy or pharmacist and the pharmacy 30
480	480	benefits manager at the time that the payment is made. 31
481	481	HOUSE BILL 1014 11
482	482
483	483
484	484	(2) A clerical error, record–keeping error, typographical error, or 1
485	485	scrivener’s error in a required document or record may not constitute fraud or grounds for 2
486	486	recoupment of a claims payment from a pharmacy or pharmacist by a pharmacy benefits 3
487	487	manager if the prescription was otherwise legally dispensed and the claim was otherwise 4
488	488	materially correct. 5
489	489
490	490	(3) Notwithstanding paragraph (2) of this subsection, claims remain 6
491	491	subject to recoupment of overpayment or payment of any discovered underpayment by the 7
492	492	pharmacy benefits manager. 8
493	493
494	494	[(k)] (J) (1) A pharmacy benefits manager shall establish an internal appeals 9
495	495	process under which a pharmacy or pharmacist may appeal any disputed claim in a 10
496	496	preliminary audit report. 11
497	497
498	498	(2) Under the internal appeals process, a pharmacy benefits manager shall 12
499	499	allow a pharmacy or pharmacist to request an internal appeal within 30 working days after 13
500	500	receipt of the preliminary audit report, with reasonable extensions allowed. 14
501	501
502	502	(3) The pharmacy benefits manager shall include in its preliminary audit 15
503	503	report a written explanation of the internal appeals process, including the name, address, 16
504	504	and telephone number of the person to whom an internal appeal should be addressed. 17
505	505
506	506	(4) The decision of the pharmacy benefits manager on an appeal of a 18
507	507	disputed claim in a preliminary audit report by a pharmacy or pharmacist shall be reflected 19
508	508	in the final audit report. 20
509	509
510	510	(5) The pharmacy benefits manager shall deliver the final audit report to 21
511	511	the pharmacy or pharmacist within 30 calendar days after conclusion of the internal 22
512	512	appeals process. 23
513	513
514	514	[(l)] (K) (1) A pharmacy benefits manager may not recoup by setoff any 24
515	515	money for an overpayment or denial of a claim until: 25
516	516
517	517	(i) the pharmacy or pharmacist has an opportunity to review the 26
518	518	pharmacy benefits manager’s findings; and 27
519	519
520	520	(ii) if the pharmacy or pharmacist concurs with the pharmacy 28
521	521	benefits manager’s findings of overpayment or denial, 30 working days have elapsed after 29
522	522	the date the final audit report has been delivered to the pharmacy or pharmacist. 30
523	523
524	524	(2) If the pharmacy or pharmacist does not concur with the pharmacy 31
525	525	benefits manager’s findings of overpayment or denial, the pharmacy benefits manager may 32
526	526	not recoup by setoff any money pending the outcome of an appeal under subsection [(k)] 33
527	527	(J) of this section. 34
528	528
529	529	(3) A pharmacy benefits manager shall remit any money due to a pharmacy 35
530	530	or pharmacist as a result of an underpayment of a claim within 30 working days after the 36 12 HOUSE BILL 1014
531	531
532	532
533	533	final audit report has been delivered to the pharmacy or pharmacist. 1
534	534
535	535	(4) Notwithstanding the provisions of paragraph (1) of this subsection, a 2
536	536	pharmacy benefits manager may withhold future payments before the date the final audit 3
537	537	report has been delivered to the pharmacy or pharmacist if the identified discrepancy for 4
538	538	all disputed claims in a preliminary audit report for an individual audit exceeds $25,000. 5
539	539
540	540	[(m)] (L) (1) The Commissioner may adopt regulations regarding: 6
541	541
542	542	(i) the documentation that may be requested during an audit; and 7
543	543
544	544	(ii) the process a pharmacy benefits manager may use to conduct an 8
545	545	audit. 9
546	546
547	547	(2) On request of the Commissioner or the Commissioner’s designee, a 10
548	548	pharmacy benefits manager shall provide a copy of its audit procedures or internal appeals 11
549	549	process. 12
550	550
551	551	15–1630. 13
552	552
553	553	(a) [This section applies only to a pharmacy benefits manager that provides 14
554	554	pharmacy benefits management services on behalf of a carrier. 15
555	555
556	556	(b)] A pharmacy benefits manager shall establish a reasonable internal review 16
557	557	process for a pharmacy to request the review of a failure to pay the contractual 17
558	558	reimbursement amount of a submitted claim. 18
559	559
560	560	[(c)] (B) A pharmacy may request a pharmacy benefits manager to review a 19
561	561	failure to pay the contractual reimbursement amount of a claim within 180 calendar days 20
562	562	after the date the submitted claim was paid by the pharmacy benefits manager. 21
563	563
564	564	[(d)] (C) The pharmacy benefits manager shall give written notice of its review 22
565	565	decision within 90 calendar days after receipt of a request for review from a pharmacy 23
566	566	under this section. 24
567	567
568	568	[(e)] (D) If the pharmacy benefits manager determines through the internal 25
569	569	review process established under subsection [(b)] (A) of this section that the pharmacy 26
570	570	benefits manager underpaid a pharmacy, the pharmacy benefits manager shall pay any 27
571	571	money due to the pharmacy within 30 working days after completion of the internal review 28
572	572	process. 29
573	573
574	574	[(f)] (E) This section may not be construed to limit the ability of a pharmacy and 30
575	575	a pharmacy benefits manager to contractually agree that a pharmacy may have more than 31
576	576	180 calendar days to request an internal review of a failure of the pharmacy benefits 32
577	577	manager to pay the contractual amount of a submitted claim. 33
578	578	HOUSE BILL 1014 13
579	579
580	580
581	581	[15–1633. 1
582	582
583	583	The provisions of §§ 15–1633.1 through 15–1639 of this subtitle apply only to a 2
584	584	pharmacy benefits manager performing pharmacy benefits management services on behalf 3
585	585	of a carrier.] 4
586	586
587	587	[15–1633.1.] 15–1633. 5
588	588
589	589	A pharmacy benefits manager or its agent may not request a therapeutic interchange 6
590	590	unless: 7
591	591
592	592	(1) the proposed therapeutic interchange is for medical reasons that benefit 8
593	593	the beneficiary; or 9
594	594
595	595	(2) the proposed therapeutic interchange will result in financial savings 10
596	596	and benefits to the purchaser or the beneficiary. 11
597	597
598	598	SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 12
599	599	January 1, 2023. 13