MD
Maryland House Bill HB374

Maryland 2023 Regular Session

Maryland House Bill HB374 Compare Versions

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1- WES MOORE, Governor Ch. 355
21
3-– 1 –
4-Chapter 355
5-(House Bill 374)
62
7-AN ACT concerning
3+EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
4+ [Brackets] indicate matter deleted from existing law.
5+ Underlining indicates amendments to bill.
6+ Strike out indicates matter stricken from the bill by amendment or deleted from the law by
7+amendment.
8+ Italics indicate opposite chamber/conference committee amendments.
9+ *hb0374*
810
9-Health Insurance – Pharmacy Benefits Managers – Audits of Pharmacies and
10-Pharmacists
11+HOUSE BILL 374
12+J5 (3lr0476)
13+ENROLLED BILL
14+— Health and Government Operations/Finance —
15+Introduced by Delegate Kipke Delegates Kipke, Alston, Bagnall, Bhandari,
16+Chisholm, Cullison, Guzzone, Hill, Hutchinson, S. Johnson, Kaiser, Kerr,
17+R. Lewis, Lopez, Martinez, M. Morgan, Pena–Melnyk, Reilly, Rosenberg,
18+Szeliga, Taveras, White, and Woods
1119
12-FOR the purpose of expanding the applicability of the provisions regarding audits of a
13-pharmacy or pharmacist to all pharmacy benefits managers; authorizing a pharmacy
14-benefits manager to conduct an audit through an auditing entity that is registered
15-with the Maryland Insurance Commissioner; requiring the Secretary of Health to
16-adopt certain regulations for pharmacy benefits managers that contract with
17-managed care organizations that establish requirements for conducting audits of
18-pharmacies or pharmacists; establishing requirements and prohibitions regarding
19-audits by certain pharmacy benefits managers, including provisions related to audit
20-limits, the acceptance of certain documents as validation or proof, the recoupment of
21-funds or charging and payment of fees for prescriptions of unbreakable package
22-sizes, access to financial documentation, and audit documentation; requiring that a
23-final audit report include certain information if applicable; authorizing a pharmacy
24-or pharmacist to confirm with a pharmacy customer or purchaser that the pharmacy
25-customer or purchaser received a certain refund; and generally relating to audits by
26-pharmacy benefits managers.
20+Read and Examined by Proofreaders:
2721
28-BY adding to
29- Article – Health – General
30-Section 15–102.3(k) 15–103(b)(33)
31- Annotated Code of Maryland
32- (2019 Replacement Volume and 2022 Supplement)
22+_______________________________________________
23+Proofreader.
24+_______________________________________________
25+Proofreader.
3326
34-BY repealing and reenacting, with amendments,
35- Article – Insurance
36-Section 15–1629
37- Annotated Code of Maryland
38- (2017 Replacement Volume and 2022 Supplement)
27+Sealed with the Great Seal and presented to the Governor, for his approval this
3928
40- SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND,
41-That the Laws of Maryland read as follows:
29+_______ day of _______________ at ________________________ o’clock, ________M.
4230
43-Article – Health – General
31+______________________________________________
32+Speaker.
4433
45-15–102.3.
46- Ch. 355 2023 LAWS OF MARYLAND
34+CHAPTER ______
4735
48-– 2 –
49- (K) THE PROVISIONS OF § 15–1629 OF THE INSURANCE ARTICLE APPLY TO
50-PHARMACY BENEFITS MA NAGERS THAT CONTRACT WITH MANAGED CARE
51-ORGANIZATIONS .
36+AN ACT concerning 1
5237
53-15–103.
38+Health Insurance – Pharmacy Benefits Managers – Audits of Pharmacies and 2
39+Pharmacists 3
5440
55- (b) (33) THE SECRETARY SHALL ADOPT REGULATIONS FOR PHAR MACY
56-BENEFITS MANAGERS TH AT CONTRACT WITH MAN AGED CARE ORGANIZATI ONS THAT
57-ESTABLISH REQUIREMEN TS FOR CONDUCTING AU DITS OF PHARMACIES O R
58-PHARMACISTS THAT ARE :
41+FOR the purpose of expanding the applicability of the provisions regarding audits of a 4
42+pharmacy or pharmacist to all pharmacy benefits managers; authorizing a pharmacy 5
43+benefits manager to conduct an audit through an auditing entity that is registered 6
44+with the Maryland Insurance Commissioner; requiring the Secretary of Health to 7
45+adopt certain regulations for pharmacy benefits managers that contract with 8
46+managed care organizations that establish requirements for conducting audits of 9
47+pharmacies or pharmacists; establishing requirements and prohibitions regarding 10
48+audits by certain pharmacy benefits managers, including provisions related to audit 11
49+limits, the acceptance of certain documents as validation or proof, the recoupment of 12 2 HOUSE BILL 374
5950
60- (I) TO THE EXTENT PRACTIC ABLE, SUBSTANTIVELY SIMILAR
61-TO THE AUDIT PROVISI ONS UNDER § 15–1629 OF THE INSURANCE ARTICLE; AND
6251
63- (II) CONSISTENT WITH FEDER AL LAW.
52+funds or charging and payment of fees for prescriptions of unbreakable package 1
53+sizes, access to financial documentation, and audit documentation; requiring that a 2
54+final audit report include certain information if applicable; authorizing a pharmacy 3
55+or pharmacist to confirm with a pharmacy customer or purchaser that the pharmacy 4
56+customer or purchaser received a certain refund; and generally relating to audits by 5
57+pharmacy benefits managers. 6
6458
65-Article – Insurance
59+BY adding to 7
60+ Article – Health – General 8
61+Section 15–102.3(k) 15–103(b)(33) 9
62+ Annotated Code of Maryland 10
63+ (2019 Replacement Volume and 2022 Supplement) 11
6664
67-15–1629.
65+BY repealing and reenacting, with amendments, 12
66+ Article – Insurance 13
67+Section 15–1629 14
68+ Annotated Code of Maryland 15
69+ (2017 Replacement Volume and 2022 Supplement) 16
6870
69- [(a) This section applies only to a pharmacy benefits manager that provides
70-pharmacy benefits management services on behalf of a carrier.]
71+ SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 17
72+That the Laws of Maryland read as follows: 18
7173
72- [(b)] (A) This section does not apply to an audit that involves probable or
73-potential fraud or willful misrepresentation by a pharmacy or pharmacist.
74+Article – Health – General 19
7475
75- [(c)] (B) A pharmacy benefits manager shall conduct an audit of a pharmacy or
76-pharmacist under contract with the pharmacy benefits manager in accordance with this
77-section.
76+15–102.3. 20
7877
79- (C) (D) (1) A PHARMACY BENEFITS MA NAGER MAY CONDUCT AN AUDIT
80-THROUGH AN AUDITING ENTITY.
78+ (K) THE PROVISIONS OF § 15–1629 OF THE INSURANCE ARTICLE APPLY TO 21
79+PHARMACY BENEFITS MA NAGERS THAT CONTRACT WITH MANAGED CARE 22
80+ORGANIZATIONS . 23
8181
82- (2) AN AUDITING ENTITY MU ST REGISTER WITH THE COMMISSIONER
83-AS AN AUDITING ENTIT Y BEFORE CONDUCTING AN AUDIT IN THE STATE.
82+15–103. 24
8483
85- (3) (2) THE COMMISSIONER MAY ADOP T REGULATIONS TO CAR RY
86-OUT THIS SUBSECTION .
84+ (b) (33) THE SECRETARY SHALL ADOPT REGULATIONS FOR PHAR MACY 25
85+BENEFITS MANAGERS TH AT CONTRACT WITH MANAGE D CARE ORGANIZATIONS THAT 26
86+ESTABLISH REQUIREMEN TS FOR CONDUCTING AU DITS OF PHARMACIES O R 27
87+PHARMACISTS THAT ARE : 28
8788
88- (d) (E) A pharmacy benefits manager may not schedule an onsite audit to begin
89-during the first 5 calendar days of a month unless requested by the pharmacy or
90-pharmacist.
89+ (I) TO THE EXTENT PRACTIC ABLE, SUBSTANTIVELY SIMILA R 29
90+TO THE AUDIT PROVISI ONS UNDER § 15–1629 OF THE INSURANCE ARTICLE; AND 30
9191
92- (e) (F) When conducting an audit, a pharmacy benefits manager shall: WES MOORE, Governor Ch. 355
92+ (II) CONSISTENT WITH FEDER AL LAW. 31
9393
94-– 3 –
94+Article – Insurance 32
9595
96- (1) if the audit is onsite, provide written notice to the pharmacy or
97-pharmacist at least 2 weeks before conducting the initial onsite audit for each audit cycle;
96+15–1629. 33
97+ HOUSE BILL 374 3
9898
99- (2) employ the services of a pharmacist if the audit requires the clinical or
100-professional judgment of a pharmacist;
10199
102- (3) [permit] ALLOW its auditors to enter the prescription area of a
103-pharmacy only when accompanied by or authorized by a member of the pharmacy staff;
100+ [(a) This section applies only to a pharmacy benefits manager that provides 1
101+pharmacy benefits management services on behalf of a carrier.] 2
104102
105- (4) allow a pharmacist or pharmacy to use any prescription, or authorized
106-change to a prescription, that meets the requirements of COMAR 10.34.20.02 to validate
107-claims submitted for reimbursement for dispensing of original and refill prescriptions;
103+ [(b)] (A) This section does not apply to an audit that involves probable or 3
104+potential fraud or willful misrepresentation by a pharmacy or pharmacist. 4
108105
109- (5) for purposes of validating the pharmacy record with respect to orders
110-or refills of a drug, allow the pharmacy or pharmacist to use records of a hospital or a
111-physician or other prescriber authorized by law that are:
106+ [(c)] (B) A pharmacy benefits manager shall conduct an audit of a pharmacy or 5
107+pharmacist under contract with the pharmacy benefits manager in accordance with this 6
108+section. 7
112109
113- (i) written; or
110+ (C) (D) (1) A PHARMACY BENEFITS MA NAGER MAY CONDUCT AN AUDIT 8
111+THROUGH AN AUDITING ENTITY. 9
114112
115- (ii) transmitted electronically or by any other means of
116-communication authorized by contract between the pharmacy and the pharmacy benefits
117-manager;
113+ (2) AN AUDITING ENTITY MU ST REGISTER WITH THE COMMISSIONER 10
114+AS AN AUDITING ENTIT Y BEFORE CONDUCTING AN AUDIT IN THE STATE. 11
118115
119- (6) FOR PURPOSES OF AN I NVOICE AUDIT, ACCEPT AS VALIDATION
120-INVOICES ISSUED BEFO RE THE DATE OF DISPE NSING FROM:
116+ (3) (2) THE COMMISSIONER MAY ADOP T REGULATIONS TO CAR RY 12
117+OUT THIS SUBSECTION . 13
121118
122- (I) A WHOLESALE DISTRIBU TOR:
119+ (d) (E) A pharmacy benefits manager may not schedule an onsite audit to begin 14
120+during the first 5 calendar days of a month unless requested by the pharmacy or 15
121+pharmacist. 16
123122
124- 1. THAT HAS BEEN ISSUED A PERMIT BY THE STATE
125-BOARD OF PHARMACY UNDER TITLE 12, SUBTITLE 6C OF THE HEALTH
126-OCCUPATIONS ARTICLE; AND
123+ (e) (F) When conducting an audit, a pharmacy benefits manager shall: 17
127124
128- 2. FROM WHICH THE PHARM ACY OR PHARMACIST HA S
129-PURCHASED PRESCRIPTI ON DRUGS; OR
125+ (1) if the audit is onsite, provide written notice to the pharmacy or 18
126+pharmacist at least 2 weeks before conducting the initial onsite audit for each audit cycle; 19
130127
131- (II) FOR INVOICES FOR DUR ABLE MEDICAL EQUIPME NT OR
132-SICKROOM SUPPLIES , A DISTRIBUTOR THAT H AS THE APPROPRIATE
133-AUTHORIZATIO N TO DO BUSINESS IN THE STATE;
128+ (2) employ the services of a pharmacist if the audit requires the clinical or 20
129+professional judgment of a pharmacist; 21
134130
135- (7) (6) ALLOW ACCEPT A COMPLETED CASH REGISTER
136-TRANSACTION TO SERVE AS PROOF OF DE LIVERY OR PICKUP FOR A PHARMACY
137-CUSTOMER UNLESS THERE IS CONT RADICTORY INFORMATIO N;
138- Ch. 355 2023 LAWS OF MARYLAND
131+ (3) [permit] ALLOW its auditors to enter the prescription area of a 22
132+pharmacy only when accompanied by or authorized by a member of the pharmacy staff; 23
139133
140-– 4 –
141- [(6)] (8) (7) audit each pharmacy and pharmacist under the same standards
142-and parameters as other similarly situated pharmacies or pharmacists audited by the
143-pharmacy benefits manager;
134+ (4) allow a pharmacist or pharmacy to use any prescription, or authorized 24
135+change to a prescription, that meets the requirements of COMAR 10.34.20.02 to validate 25
136+claims submitted for reimbursement for dispensing of original and refill prescriptions; 26
144137
145- [(7)] (9) (8) only audit claims submitted or adjudicated within the 2–year
146-period immediately preceding the audit, unless a longer period is authorized under federal
147-or State law;
138+ (5) for purposes of validating the pharmacy record with respect to orders 27
139+or refills of a drug, allow the pharmacy or pharmacist to use records of a hospital or a 28
140+physician or other prescriber authorized by law that are: 29
148141
149- [(8)] (10) (9) deliver the preliminary audit report to the pharmacy or
150-pharmacist within 120 calendar days after the completion of the audit, with reasonable
151-extensions allowed;
142+ (i) written; or 30
143+ 4 HOUSE BILL 374
152144
153- [(9)] (11) (10) in accordance with subsection [(k)] (M) (L) (M) of this
154-section, allow a pharmacy or pharmacist to produce documentation to address any
155-discrepancy found during the audit; and
156145
157- [(10)] (12) (11) deliver the final audit report to the pharmacy or
158-pharmacist:
146+ (ii) transmitted electronically or by any other means of 1
147+communication authorized by contract between the pharmacy and the pharmacy benefits 2
148+manager; 3
159149
160- (i) within 6 months after delivery of the preliminary audit report if
161-the pharmacy or pharmacist does not request an internal appeal under subsection [(k)] (M)
162-(L) (M) of this section; or
150+ (6) FOR PURPOSES OF AN I NVOICE AUDIT, ACCEPT AS VALIDATION 4
151+INVOICES ISSUED BEFO RE THE DATE OF DISPE NSING FROM: 5
163152
164- (ii) within 30 days after the conclusion of the internal appeals
165-process under subsection [(k)] (M) (L) (M) of this section if the pharmacy or pharmacist
166-requests an internal appeal.
153+ (I) A WHOLESAL E DISTRIBUTOR: 6
167154
168- (f) (G) If a contract between a pharmacy or pharmacist and a pharmacy
169-benefits manager specifies a period of time in which a pharmacy or pharmacist is allowed
170-to withdraw and resubmit a claim and that period of time expires before the pharmacy
171-benefits manager delivers a preliminary audit report that identifies discrepancies, the
172-pharmacy benefits manager shall allow the pharmacy or pharmacist to withdraw and
173-resubmit a claim within 30 days after:
155+ 1. THAT HAS BEEN ISSUED A PERMIT BY THE STATE 7
156+BOARD OF PHARMACY UNDER TITLE 12, SUBTITLE 6C OF THE HEALTH 8
157+OCCUPATIONS ARTICLE; AND 9
174158
175- (1) the preliminary audit report is delivered if the pharmacy or pharmacist
176-does not request an internal appeal under subsection [(k)] (M) (L) (M) of this section; or
159+ 2. FROM WHICH THE PHARM ACY OR PHARMACIST HA S 10
160+PURCHASED PRESCRIPTI ON DRUGS; OR 11
177161
178- (2) the conclusion of the internal appeals process under subsection [(k)]
179-(M) (L) (M) of this section if the pharmacy or pharmacist requests an internal appeal.
162+ (II) FOR INVOICES FOR DURABLE MEDICAL EQUIPMENT OR 12
163+SICKROOM SUPPLIES , A DISTRIBUTOR THAT H AS THE APPROPRIATE 13
164+AUTHORIZATION TO DO BUSINESS IN THE STATE; 14
180165
181- (g) (H) During an audit, a pharmacy benefits manager may not disrupt the
182-provision of services to the customers of a pharmacy.
166+ (7) (6) ALLOW ACCEPT A COMPLETED CASH REGISTER 15
167+TRANSACTION TO SERVE AS PROOF OF DE LIVERY OR PICKUP FOR A PHARMACY 16
168+CUSTOMER UNLESS THERE IS CONT RADICTORY INFORMATIO N; 17
183169
184- (h) (I) (1) A pharmacy benefits manager may not:
185- WES MOORE, Governor Ch. 355
170+ [(6)] (8) (7) audit each pharmacy and pharmacist under the same standards 18
171+and parameters as other similarly situated pharmacies or pharmacists audited by the 19
172+pharmacy benefits manager; 20
186173
187-– 5 –
188- (i) use the accounting practice of extrapolation to calculate
189-overpayments or underpayments; [or]
174+ [(7)] (9) (8) only audit claims submitted or adjudicated within the 2–year 21
175+period immediately preceding the audit, unless a longer period is authorized under federal 22
176+or State law; 23
190177
191- (ii) [Except] EXCEPT as provided in paragraph (2) of this subsection:
178+ [(8)] (10) (9) deliver the preliminary audit report to the pharmacy or 24
179+pharmacist within 120 calendar days after the completion of the audit, with reasonable 25
180+extensions allowed; 26
192181
193- 1. share information from an audit with another pharmacy
194-benefits manager; or
182+ [(9)] (11) (10) in accordance with subsection [(k)] (M) (L) (M) of this 27
183+section, allow a pharmacy or pharmacist to produce documentation to address any 28
184+discrepancy found during the audit; and 29
195185
196- 2. use information from an audit conducted by another
197-pharmacy benefits manager;
186+ [(10)] (12) (11) deliver the final audit report to the pharmacy or 30
187+pharmacist: 31
188+ HOUSE BILL 374 5
198189
199- (III) CHARGE A PHARMACY OR PHARMACIST A FEE UNL ESS AN
200-AUDIT FINDS THERE WA S A FINANCIAL DETRIM ENT TO THE PHARMACY CUSTOMER
201-OR PURCHASER ;
202190
203- (IV) CHARGE A PHARMACY OR PHARMACIST A FEE WIT H REGARD
204-TO AN INCORRECT DAYS OF SUPPLY CALCULATIO N IF THE PHARMACY BE NEFITS
205-MANAGER IS UNABLE T O ACCEPT THE CORRECT DAYS OF SUPPLY WITHO UT HELP
206-DESK INTERVENTION ;
191+ (i) within 6 months after delivery of the preliminary audit report if 1
192+the pharmacy or pharmacist does not request an internal appeal under subsection [(k)] (M) 2
193+(L) (M) of this section; or 3
207194
208- (III) RECOUP ANY FUNDS FRO M OR CHARGE ANY FEES TO A
209-PHARMACY OR PHARMACI ST FOR A PRESCRIPTIO N WITH REGARD TO AN INCORRECT
210-DAYS OF SUPPLY CALCU LATION IF THE PACKAG E SIZE OF THE MEDICATION IS
211-UNBREAKABLE AND THE PHARMACY BENEFITS MA NAGER CANNOT ACCEPT THE
212-CORRECT MATHEMATICAL LY CALCULABLE DAYS ’ SUPPLY DURING PRESCR IPTION
213-ADJUDICATION ;
195+ (ii) within 30 days after the conclusion of the internal appeals 4
196+process under subsection [(k)] (M) (L) (M) of this section if the pharmacy or pharmacist 5
197+requests an internal appeal. 6
214198
215- (V) (IV) HAVE OR REQUEST ACCE SS TO A PHARMACY ’S OR
216-PHARMACIST ’S BANK, CREDIT CARD, OR DEPOSITORY STATEMENTS OR D ATA AS IT
217-RELATES TO COST –SHARING; OR
199+ (f) (G) If a contract between a pharmacy or pharmacist and a pharmacy 7
200+benefits manager specifies a period of time in which a pharmacy or pharmacist is allowed 8
201+to withdraw and resubmit a claim and that period of time expires before the pharmacy 9
202+benefits manager delivers a preliminary audit report that identifies discrepancies, the 10
203+pharmacy benefits manager shall allow the pharmacy or pharmacist to withdraw and 11
204+resubmit a claim within 30 days after: 12
218205
219- (VI) (V) AUDIT CLAIMS THAT WE RE REVERSED OR FOR W HICH
220-THERE WAS NO REMUNER ATION BY THE PURCHAS ER OR COST TO THE PH ARMACY
221-CUSTOMER EXCEPT IF NECESSARY TO EVALUATE COMPLIAN CE TO A CONTRACT .
206+ (1) the preliminary audit report is delivered if the pharmacy or pharmacist 13
207+does not request an internal appeal under subsection [(k)] (M) (L) (M) of this section; or 14
222208
223- (2) Paragraph (1)(ii) of this subsection does not apply to the sharing of
224-information:
209+ (2) the conclusion of the internal appeals process under subsection [(k)] 15
210+(M) (L) (M) of this section if the pharmacy or pharmacist requests an internal appeal. 16
225211
226- (i) required by federal or State law;
212+ (g) (H) During an audit, a pharmacy benefits manager may not disrupt the 17
213+provision of services to the customers of a pharmacy. 18
227214
228- (ii) in connection with an acquisition or merger involving the
229-pharmacy benefits manager; or
215+ (h) (I) (1) A pharmacy benefits manager may not: 19
230216
231- (iii) at the payor’s request or under the terms of the agreement
232-between the pharmacy benefits manager and the payor. Ch. 355 2023 LAWS OF MARYLAND
217+ (i) use the accounting practice of extrapolation to calculate 20
218+overpayments or underpayments; [or] 21
233219
234-– 6 –
220+ (ii) [Except] EXCEPT as provided in paragraph (2) of this subsection: 22
235221
236- (3) FOR CLAIMS THAT WERE AUDITED IN VIOLATION OF PARAGRAPH
237-(1)(VI) OF THIS SUBSECTION , THE PHARMACY BENEFIT S MANAGER OR PURCHAS ER
238-SHALL PAY THE PHARMA CY OR PHARMACIST $20 PER CLAIM FOUND TO B E IN
239-VIOLATION.
222+ 1. share information from an audit with another pharmacy 23
223+benefits manager; or 24
240224
241- (I) (J) (1) A PHARMACY BENEFITS MA NAGER OR PURCHASER M AY NOT
242-AUDIT MORE THAN 50 125 PRESCRIPTIONS DURING A DESK OR SITE AUDIT UNLESS
243-THE PHARMACY BENEFITS MA NAGER OR PURCHASER R EQUESTING THE AUDIT PAYS
244-THE PHARMACY OR PHARMACI ST $20 PER ADDITIONAL PRESC RIPTION OR PROOF
245-OF DELIVERY OR PICKUP R EQUEST.
225+ 2. use information from an audit conducted by another 25
226+pharmacy benefits manager; 26
246227
247- (2) THE FEE REQUIRED UNDE R PARAGRAPH (1) OF THIS SUBSECTION
248-IS IN ADDITION TO TH E FEE REQUIRED UNDER SUBSECTION (J)(1) OF THIS SECTION.
228+ (III) CHARGE A PHARMACY OR PHARMACIST A FEE UNL ESS AN 27
229+AUDIT FINDS THERE WA S A FINANCIAL DETRIMENT TO T HE PHARMACY CUSTOMER 28
230+OR PURCHASER ; 29
249231
250- (J) (1) SUBJECT TO PARAGRAPH (2) OF THIS SUBSECTION , A PHARMACY
251-BENEFITS MANAGER OR PURCHASER SHALL PAY A PHARMACY OR PHARMA CIST $250
252-PER HOUR OF AUDIT OR $10 PER PRESCRIPTION AUD ITED, WHICHEVER IS GREATER .
232+ (IV) CHARGE A PHARMACY OR PHARMACIST A FEE WIT H REGARD 30
233+TO AN INCORRECT DAYS OF SUPPLY CALCULATIO N IF THE PHARMACY BE NEFITS 31
234+MANAGER IS UNABLE TO ACCEPT THE CORRECT D AYS OF SUPPLY WITHOU T HELP 32
235+DESK INTERVENTION ; 33 6 HOUSE BILL 374
253236
254- (2) THE FEE REQUIRED UNDE R THIS SUBSECTION SH ALL BE
255-ADJUSTED ON JULY 1 EACH YEAR FOR INFLAT ION IN ACCORDANCE WI TH THE
256-CONSUMER PRICE INDEX.
257237
258- [(i)] (K) (J) (K) The recoupment of a claims payment from a pharmacy or
259-pharmacist by a pharmacy benefits manager shall be based on an actual overpayment or
260-denial of an audited claim unless the projected overpayment or denial is part of a settlement
261-agreed to by the pharmacy or pharmacist.
262238
263- [(j)] (L) (K) (L) (1) In this subsection, “overpayment” means a payment by the
264-pharmacy benefits manager to a pharmacy or pharmacist that is greater than the rate or
265-terms specified in the contract between the pharmacy or pharmacist and the pharmacy
266-benefits manager at the time that the payment is made.
239+ (III) RECOUP ANY FUNDS FRO M OR CHARGE ANY FEES TO A 1
240+PHARMACY OR PHARMACI ST FOR A PRESCRIPTIO N WITH REGARD TO AN INCORRECT 2
241+DAYS OF SUPPLY CALCU LATION IF THE PACKAG E SIZE OF THE MEDICA TION IS 3
242+UNBREAKABLE AND THE PHARMACY BENEFITS MA NAGER CANNOT ACCEPT THE 4
243+CORRECT MATHEMATICAL LY CALCULABLE DAYS ’ SUPPLY DURING PRESCR IPTION 5
244+ADJUDICATION ; 6
267245
268- (2) A clerical error, record–keeping error, typographical error, or
269-scrivener’s error in a required document or record may not constitute fraud or grounds for
270-recoupment of a claims payment from a pharmacy or pharmacist by a pharmacy benefits
271-manager if the prescription was otherwise legally dispensed and the claim was otherwise
272-materially correct.
246+ (V) (IV) HAVE OR REQUEST ACCE SS TO A PHARMACY ’S OR 7
247+PHARMACIST ’S BANK, CREDIT CARD, OR DEPOSITORY STATEM ENTS OR DATA AS IT 8
248+RELATES TO COST –SHARING; OR 9
273249
274- (3) Notwithstanding paragraph (2) of this subsection, claims remain
275-subject to recoupment of overpayment or payment of any discovered underpayment by the
276-pharmacy benefits manager.
277- WES MOORE, Governor Ch. 355
250+ (VI) (V) AUDIT CLAIMS THAT WE RE REVERSED OR FOR W HICH 10
251+THERE WAS NO REMUNER ATION BY THE PURCHAS ER OR COST TO THE PH ARMACY 11
252+CUSTOMER EXCEPT IF NECESSARY TO EVALUATE COMPLIAN CE TO A CONTRACT . 12
278253
279-– 7 –
280- [(k)] (M) (L) (M) (1) A pharmacy benefits manager shall establish an internal
281-appeals process under which a pharmacy or pharmacist may appeal any disputed claim in
282-a preliminary audit report.
254+ (2) Paragraph (1)(ii) of this subsection does not apply to the sharing of 13
255+information: 14
283256
284- (2) Under the internal appeals process, a pharmacy benefits manager shall
285-allow a pharmacy or pharmacist to request an internal appeal within 30 working days after
286-receipt of the preliminary audit report, with reasonable extensions allowed.
257+ (i) required by federal or State law; 15
287258
288- (3) The pharmacy benefits manager shall include in its preliminary audit
289-report a written explanation of the internal appeals process, including the name, address,
290-and telephone number of the person to whom an internal appeal should be addressed.
259+ (ii) in connection with an acquisition or merger involving the 16
260+pharmacy benefits manager; or 17
291261
292- (4) The decision of the pharmacy benefits manager on an appeal of a
293-disputed claim in a preliminary audit report by a pharmacy or pharmacist shall be reflected
294-in the final audit report.
262+ (iii) at the payor’s request or under the terms of the agreement 18
263+between the pharmacy benefits manager and the payor. 19
295264
296- (5) The pharmacy benefits manager shall deliver the final audit report to
297-the pharmacy or pharmacist within 30 calendar days after conclusion of the internal
298-appeals process.
265+ (3) FOR CLAIMS THAT WERE AUDITED IN VIOLATION OF PARAGRAPH 20
266+(1)(VI) OF THIS SUBSECTION , THE PHARMACY BENEFIT S MANAGER OR PURCHAS ER 21
267+SHALL PAY THE PHARMA CY OR PHARMACIST $20 PER CLAIM FOUND TO B E IN 22
268+VIOLATION. 23
299269
300- [(l)] (N) (M) (N) (1) A pharmacy benefits manager may not recoup by setoff
301-any money for an overpayment or denial of a claim until:
270+ (I) (J) (1) A PHARMACY BENEFITS MA NAGER OR PURCHASER M AY NOT 24
271+AUDIT MORE THAN 50 125 PRESCRIPTIONS DURING A DESK OR SITE AUDIT UNLESS 25
272+THE PHARMACY BENEFITS MA NAGER OR PURCHASER R EQUESTING THE AUDIT PAYS 26
273+THE PHARMACY OR PHARMACI ST $20 PER ADDITIONAL PRESC RIPTION OR PROOF 27
274+OF DELIVERY OR PICKUP R EQUEST. 28
302275
303- (i) the pharmacy or pharmacist has an opportunity to review the
304-pharmacy benefits manager’s findings; and
276+ (2) THE FEE REQUIRED UNDE R PARAGRAPH (1) OF THIS SUBSECTION 29
277+IS IN ADDITION TO TH E FEE REQUIRED UNDER SUBSECTION (J)(1) OF THIS SECTION. 30
305278
306- (ii) if the pharmacy or pharmacist concurs with the pharmacy
307-benefits manager’s findings of overpayment or denial, 30 working days have elapsed after
308-the date the final audit report has been delivered to the pharmacy or pharmacist.
279+ (J) (1) SUBJECT TO PARAGRAPH (2) OF THIS SUBSECTION , A PHARMACY 31
280+BENEFITS MANAG ER OR PURCHASER SHAL L PAY A PHARMACY OR PHARMACIST $250 32
281+PER HOUR OF AUDIT OR $10 PER PRESCRIPTION AUD ITED, WHICHEVER IS GREATER . 33
282+ HOUSE BILL 374 7
309283
310- (2) If the pharmacy or pharmacist does not concur with the pharmacy
311-benefits manager’s findings of overpayment or denial, the pharmacy benefits manager may
312-not recoup by setoff any money pending the outcome of an appeal under subsection [(k)]
313-(M) (L) (M) of this section.
314284
315- (3) A pharmacy benefits manager shall remit any money due to a pharmacy
316-or pharmacist as a result of an underpayment of a claim within 30 working days after the
317-final audit report has been delivered to the pharmacy or pharmacist.
285+ (2) THE FEE REQUIRED UNDE R THIS SUBSECTION SH ALL BE 1
286+ADJUSTED ON JULY 1 EACH YEAR FOR INFLAT ION IN ACCORDANCE WI TH THE 2
287+CONSUMER PRICE INDEX. 3
318288
319- (4) Notwithstanding the provisions of paragraph (1) of this subsection, a
320-pharmacy benefits manager may withhold future payments before the date the final audit
321-report has been delivered to the pharmacy or pharmacist if the identified discrepancy for
322-all disputed claims in a preliminary audit report for an individual audit exceeds $25,000.
289+ [(i)] (K) (J) (K) The recoupment of a claims payment from a pharmacy or 4
290+pharmacist by a pharmacy benefits manager shall be based on an actual overpayment or 5
291+denial of an audited claim unless the projected overpayment or denial is part of a settlement 6
292+agreed to by the pharmacy or pharmacist. 7
323293
324- (O) THE FINAL AUDIT REPOR T SHALL, IF APPLICABLE:
325- Ch. 355 2023 LAWS OF MARYLAND
294+ [(j)] (L) (K) (L) (1) In this subsection, “overpayment” means a payment by the 8
295+pharmacy benefits manager to a pharmacy or pharmacist that is greater than the rate or 9
296+terms specified in the contract between the pharmacy or pharmacist and the pharmacy 10
297+benefits manager at the time that the payment is made. 11
326298
327-– 8 –
328- (1) IDENTIFY EACH PHARMA CY CUSTOMER OR PURCH ASER
329-RECEIVING A REFUND ; AND
299+ (2) A clerical error, record–keeping error, typographical error, or 12
300+scrivener’s error in a required document or record may not constitute fraud or grounds for 13
301+recoupment of a claims payment from a pharmacy or pharmacist by a pharmacy benefits 14
302+manager if the prescription was otherwise legally dispensed and the claim was otherwise 15
303+materially correct. 16
330304
331- (2) SPECIFY THE AMOUNT B EING REFUNDED TO EAC H PHARMACY
332-CUSTOMER OR PURCHASE R.
305+ (3) Notwithstanding paragraph (2) of this subsection, claims remain 17
306+subject to recoupment of overpayment or payment of any discovered underpayment by the 18
307+pharmacy benefits manager. 19
333308
334- (P) A PHARMACY OR PHARMACI ST MAY CONFIRM WITH THE PHARMACY
335-CUSTOMER OR PURCHASE R THAT THE PHARMACY CUSTOMER OR PURCHASE R
336-RECEIVED THE REFUND AMOUNT FROM THE PHAR MACY BENEFITS MANAGE R.
309+ [(k)] (M) (L) (M) (1) A pharmacy benefits manager shall establish an internal 20
310+appeals process under which a pharmacy or pharmacist may appeal any disputed claim in 21
311+a preliminary audit report. 22
337312
338- (Q) (N) (O) (1) A PHARMACY BENEFITS MA NAGER SHALL PROVIDE A
339-PHARMACY OR PHARMACI ST BEING AUDITED WIT H A PHONE NUMBER AND, IF
340-AVAILABLE, ACCESS TO A SECURE P ORTAL THAT THE PHARMACY OR PHARMACIST
341-MAY USE TO ASK QUEST IONS REGARDING THE A UDIT.
313+ (2) Under the internal appeals process, a pharmacy benefits manager shall 23
314+allow a pharmacy or pharmacist to request an internal appeal within 30 working days after 24
315+receipt of the preliminary audit report, with reasonable extensions allowed. 25
342316
343- (2) AN INDIVIDUAL WHO IS FAMILIAR WITH THE AUDIT SHALL
344-RESPOND TO ALL TELEPHONE INQUIRIES MADE THROUGH A PHONE NUMBER OR
345-SECURE PORTAL PROVID ED UNDER PARAGRAPH (1) OF THIS SUBSECTION WITHIN
346-72 HOURS 3 BUSINESS DAYS AFTER THE CALL INQUIRY WAS MADE.
317+ (3) The pharmacy benefits manager shall include in its preliminary audit 26
318+report a written explanation of the internal appeals process, including the name, address, 27
319+and telephone number of the person to whom an internal appeal should be addressed. 28
347320
348- (R) (O) (P) (1) THE PHARMACY BENEFITS MANAGER SHA LL GIVE THE
349-PHARMACY OR PHARMACI ST THE OPTION TO PRO VIDE REQUESTED AUDIT
350-DOCUMENTATION BY POS TAL MAIL, E–MAIL, OR FACSIMILE.
321+ (4) The decision of the pharmacy benefits manager on an appeal of a 29
322+disputed claim in a preliminary audit report by a pharmacy or pharmacist shall be reflected 30
323+in the final audit report. 31
351324
352- (2) IF A DOCUMENT IS REQU ESTED REGARDING AN A UDIT, THE
353-PHARMACY BENEFITS MA NAGER SHALL PROVIDE A SECURE FACS IMILE NUMBER
354-AND A MECHANISM FOR RECEIVING SECURE E –MAILS.
325+ (5) The pharmacy benefits manager shall deliver the final audit report to 32
326+the pharmacy or pharmacist within 30 calendar days after conclusion of the internal 33
327+appeals process. 34
355328
356- (3) ON OR BEFORE OCTOBER 1, 2025, A PHARMACY BENEFITS
357-MANAGER SHALL PROVID E A MECHANISM FOR SE CURE ELECTRONIC
358-COMMUNICATION FOR PH ARMACIES AND PHARMAC ISTS TO COMMUNICATE WITH
359-AND SUBMIT DOCUMEN TS TO THE AUDITING E NTITY.
329+ [(l)] (N) (M) (N) (1) A pharmacy benefits manager may not recoup by setoff 35
330+any money for an overpayment or denial of a claim until: 36 8 HOUSE BILL 374
360331
361- [(m)] (S) (P) (Q) (1) The Commissioner may adopt regulations regarding:
362332
363- (i) the documentation that may be requested during an audit; and
364333
365- (ii) the process a pharmacy benefits manager may use to conduct an
366-audit.
334+ (i) the pharmacy or pharmacist has an opportunity to review the 1
335+pharmacy benefits manager’s findings; and 2
367336
368- (2) On request of the Commissioner or the Commissioner’s designee, a
369-pharmacy benefits manager shall provide a copy of its audit procedures or internal appeals
370-process.
371- WES MOORE, Governor Ch. 355
337+ (ii) if the pharmacy or pharmacist concurs with the pharmacy 3
338+benefits manager’s findings of overpayment or denial, 30 working days have elapsed after 4
339+the date the final audit report has been delivered to the pharmacy or pharmacist. 5
372340
373-– 9 –
374- SECTION 2. AND BE IT FURTHER ENACTED, That:
341+ (2) If the pharmacy or pharmacist does not concur with the pharmacy 6
342+benefits manager’s findings of overpayment or denial, the pharmacy benefits manager may 7
343+not recoup by setoff any money pending the outcome of an appeal under subsection [(k)] 8
344+(M) (L) (M) of this section. 9
375345
376- (a) Except as provided in subsection (b) of this section, for an audit of a pharmacy
377-or pharmacist under contract with a pharmacy benefits manager, this Act shall apply only
378-to an audit performed on or after January 1, 2024.
346+ (3) A pharmacy benefits manager shall remit any money due to a pharmacy 10
347+or pharmacist as a result of an underpayment of a claim within 30 working days after the 11
348+final audit report has been delivered to the pharmacy or pharmacist. 12
379349
380- (b) For a pharmacy benefits manager that contracts with the State or a local
381-government, this Act shall apply only to audits that occur on the first day of the first plan
382-year beginning on or after January 1, 2024, or the first time a contract between a pharmacy
383-benefits manager with the State or a local government is amended or renewed on or after
384-January 1, 2024.
350+ (4) Notwithstanding the provisions of paragraph (1) of this subsection, a 13
351+pharmacy benefits manager may withhold future payments before the date the final audit 14
352+report has been delivered to the pharmacy or pharmacist if the identified discrepancy for 15
353+all disputed claims in a preliminary audit report for an individual audit exceeds $25,000. 16
385354
386- SECTION 2. 3. AND BE IT FURTHER ENACTED, That this Act shall take effect
387-October 1, 2023 January 1, 2024.
355+ (O) THE FINAL AUDIT REPOR T SHALL, IF APPLICABLE: 17
388356
389-Approved by the Governor, May 3, 2023.
357+ (1) IDENTIFY EACH PHARMA CY CUSTOMER OR PURCH ASER 18
358+RECEIVING A REFUND ; AND 19
359+
360+ (2) SPECIFY THE AMOUNT B EING REFUNDED TO EAC H PHARMACY 20
361+CUSTOMER OR PURCHASE R. 21
362+
363+ (P) A PHARMACY OR PHARMACI ST MAY CONFIRM WITH THE PHARMACY 22
364+CUSTOMER OR PURCHASER THAT THE P HARMACY CUSTOMER OR PURCHASER 23
365+RECEIVED THE REFUND AMOUNT FROM THE PHAR MACY BENEFITS MANAGE R. 24
366+
367+ (Q) (N) (O) (1) A PHARMACY BENEFITS MA NAGER SHALL PROVIDE A 25
368+PHARMACY OR PHARMACI ST BEING AUDITED WIT H A PHONE NUMBER AND, IF 26
369+AVAILABLE, ACCESS TO A SECURE P ORTAL THAT THE PHARMACY OR PHARMACIST 27
370+MAY USE TO ASK QUEST IONS REGARDING THE A UDIT. 28
371+
372+ (2) AN INDIVIDUAL WHO IS FAMILIAR WITH THE AU DIT SHALL 29
373+RESPOND TO ALL TELEPHONE INQUIRIES MADE THROUGH A PHONE NUMBER OR 30
374+SECURE PORTAL PROVID ED UNDER PARAGRAPH (1) OF THIS SUBSECTION WITHIN 31
375+72 HOURS 3 BUSINESS DAYS AFTER THE CALL INQUIRY WAS MADE. 32
376+ HOUSE BILL 374 9
377+
378+
379+ (R) (O) (P) (1) THE PHARMACY BENEFITS MANAGER SHALL GIVE T HE 1
380+PHARMACY OR PHARMACI ST THE OPTION TO PRO VIDE REQUESTED AUDIT 2
381+DOCUMENTATION BY POS TAL MAIL, E–MAIL, OR FACSIMILE. 3
382+
383+ (2) IF A DOCUMENT IS REQU ESTED REGARDING AN A UDIT, THE 4
384+PHARMACY BENEFITS MA NAGER SHALL PROVIDE A SECURE FACSIMILE N UMBER 5
385+AND A MECHANISM FOR RECEIVING SECURE E –MAILS. 6
386+
387+ (3) ON OR BEFORE OCTOBER 1, 2025, A PHARMACY BENEFITS 7
388+MANAGER SHALL PROVIDE A ME CHANISM FOR SECURE E LECTRONIC 8
389+COMMUNICATION FOR PH ARMACIES AND PHARMAC ISTS TO COMMUNICATE WITH 9
390+AND SUBMIT DOCUMENTS TO THE AUDITING ENTI TY. 10
391+
392+ [(m)] (S) (P) (Q) (1) The Commissioner may adopt regulations regarding: 11
393+
394+ (i) the documentation that may be requested during an audit; and 12
395+
396+ (ii) the process a pharmacy benefits manager may use to conduct an 13
397+audit. 14
398+
399+ (2) On request of the Commissioner or the Commissioner’s designee, a 15
400+pharmacy benefits manager shall provide a copy of its audit procedures or internal appeals 16
401+process. 17
402+
403+ SECTION 2. AND BE IT FURTHER ENACTED, That: 18
404+
405+ (a) Except as provided in subsection (b) of this section, for an audit of a pharmacy 19
406+or pharmacist under contract with a pharmacy benefits manager, this Act shall apply only 20
407+to an audit performed on or after January 1, 2024. 21
408+
409+ (b) For a pharmacy benefits manager that contracts with the State or a local 22
410+government, this Act shall apply only to audits that occur on the first day of the first plan 23
411+year beginning on or after January 1, 2024, or the first time a contract between a pharmacy 24
412+benefits manager with the State or a local government is amended or renewed on or after 25
413+January 1, 2024. 26
414+
415+ SECTION 2. 3. AND BE IT FURTHER ENACTED, That this Act shall take effect 27
416+October 1, 2023 January 1, 2024. 28
417+
418+
419+