Maryland 2025 Regular Session

Maryland Senate Bill SB303 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 EXISTIN G LAW.
4	4	[Brackets] indicate matter deleted from existing law.
5	5	sb0303
6	6
7	7	SENATE BILL 303
8	8	J5 5lr2166
9	9	HB 726/24 – HGO CF HB 321
10	10	By: Senator Lam
11	11	Introduced and read first time: January 13, 2025
12	12	Assigned to: Finance
13	13
14	14	A BILL ENTITLED
15	15
16	16	AN ACT concerning 1
17	17
18	18	Pharmacy Benefits Managers – Definition of Purchaser and Alteration of 2
19	19	Application of Law 3
20	20
21	21	FOR the purpose of altering the definition of “purchaser” for the purpose of certain 4
22	22	provisions of State insurance law governing pharmacy benefits managers to exclude 5
23	23	certain nonprofit health maintenance organizations; repealing certain provisions 6
24	24	that restrict the applicability of certain provisions of law to pharmacy benefits 7
25	25	managers that provide pharmacy benefits management services on behalf of a 8
26	26	carrier; and generally relating to pharmacy benefits managers. 9
27	27
28	28	BY repealing and reenacting, with amendments, 10
29	29	Article – Insurance 11
30	30	Section 15–1601, 15–1611, 15–1611.1, 15–1612, 15–1622, 15–1629, and 12
31	31	15–1630 13
32	32	Annotated Code of Maryland 14
33	33	(2017 Replacement Volume and 2024 Supplement) 15
34	34
35	35	SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 16
36	36	That the Laws of Maryland read as follows: 17
37	37
38	38	Article – Insurance 18
39	39
40	40	15–1601. 19
41	41
42	42	(a) In this subtitle the following words have the meanings indicated. 20
43	43
44	44	(b) “Agent” means a pharmacy, a pharmacist, a mail order pharmacy, or a 21
45	45	nonresident pharmacy acting on behalf or at the direction of a pharmacy benefits manager. 22
46	46
47	47	(c) “Beneficiary” means an individual who receives prescription drug coverage or 23
48	48	benefits from a purchaser. 24 2 SENATE BILL 303
49	49
50	50
51	51
52	52	(d) (1) “Carrier” means the State Employee and Retiree Health and Welfare 1
53	53	Benefits Program, an insurer, a nonprofit health service plan, or a health maintenance 2
54	54	organization that: 3
55	55
56	56	(i) provides prescription drug coverage or benefits in the State; and 4
57	57
58	58	(ii) enters into an agreement with a pharmacy benefits manager for 5
59	59	the provision of pharmacy benefits management services. 6
60	60
61	61	(2) “Carrier” does not include a person that provides prescription drug 7
62	62	coverage or benefits through plans subject to ERISA and does not provide prescription drug 8
63	63	coverage or benefits through insurance, unless the person is a multiple employer welfare 9
64	64	arrangement as defined in § 514(b)(6)(A)(ii) of ERISA. 10
65	65
66	66	(e) “Compensation program” means a program, policy, or process through which 11
67	67	sources and pricing information are used by a pharmacy benefits manager to determine the 12
68	68	terms of payment as stated in a participating pharmacy contract. 13
69	69
70	70	(f) “Contracted pharmacy” means a pharmacy that participates in the network of 14
71	71	a pharmacy benefits manager through a contract with: 15
72	72
73	73	(1) the pharmacy benefits manager; or 16
74	74
75	75	(2) a pharmacy services administration organization or a group purchasing 17
76	76	organization. 18
77	77
78	78	(g) “ERISA” has the meaning stated in § 8–301 of this article. 19
79	79
80	80	(h) “Formulary” means a list of prescription drugs used by a purchaser. 20
81	81
82	82	(i) (1) “Manufacturer payments” means any compensation or remuneration a 21
83	83	pharmacy benefits manager receives from or on behalf of a pharmaceutical manufacturer. 22
84	84
85	85	(2) “Manufacturer payments” includes: 23
86	86
87	87	(i) payments received in accordance with agreements with 24
88	88	pharmaceutical manufacturers for formulary placement and, if applicable, drug utilization; 25
89	89
90	90	(ii) rebates, regardless of how categorized; 26
91	91
92	92	(iii) market share incentives; 27
93	93
94	94	(iv) commissions; 28
95	95
96	96	(v) fees under products and services agreements; 29
97	97	SENATE BILL 303 3
98	98
99	99
100	100	(vi) any fees received for the sale of utilization data to a 1
101	101	pharmaceutical manufacturer; and 2
102	102
103	103	(vii) administrative or management fees. 3
104	104
105	105	(3) “Manufacturer payments” does not include purchase discounts based on 4
106	106	invoiced purchase terms. 5
107	107
108	108	(j) “Nonprofit health maintenance organization” has the meaning stated in § 6
109	109	6–121(a) of this article. 7
110	110
111	111	(k) “Nonresident pharmacy” has the meaning stated in § 12–403 of the Health 8
112	112	Occupations Article. 9
113	113
114	114	(l) “Participating pharmacy contract” means a contract filed with the 10
115	115	Commissioner in accordance with § 15–1628(b) of this subtitle. 11
116	116
117	117	(m) “Pharmacist” has the meaning stated in § 12–101 of the Health Occupations 12
118	118	Article. 13
119	119
120	120	(n) “Pharmacy” has the meaning stated in § 12–101 of the Health Occupations 14
121	121	Article. 15
122	122
123	123	(o) “Pharmacy and therapeutics committee” means a committee established by a 16
124	124	pharmacy benefits manager to: 17
125	125
126	126	(1) objectively appraise and evaluate prescription drugs; and 18
127	127
128	128	(2) make recommendations to a purchaser regarding the selection of drugs 19
129	129	for the purchaser’s formulary. 20
130	130
131	131	(p) (1) “Pharmacy benefits management services” means: 21
132	132
133	133	(i) the procurement of prescription drugs at a negotiated rate for 22
134	134	dispensation within the State to beneficiaries; 23
135	135
136	136	(ii) the administration or management of prescription drug coverage 24
137	137	provided by a purchaser for beneficiaries; and 25
138	138
139	139	(iii) any of the following services provided with regard to the 26
140	140	administration of prescription drug coverage: 27
141	141
142	142	1. mail service pharmacy; 28
143	143
144	144	2. claims processing, retail network management, and 29
145	145	payment of claims to pharmacies for prescription drugs dispensed to beneficiaries; 30
146	146	4 SENATE BILL 303
147	147
148	148
149	149	3. clinical formulary development and management services; 1
150	150
151	151	4. rebate contracting and administration; 2
152	152
153	153	5. patient compliance, therapeutic intervention, and generic 3
154	154	substitution programs; or 4
155	155
156	156	6. disease management programs. 5
157	157
158	158	(2) “Pharmacy benefits management services” does not include any service 6
159	159	provided by a nonprofit health maintenance organization that operates as a group model, 7
160	160	provided that the service: 8
161	161
162	162	(i) is provided solely to a member of the nonprofit health 9
163	163	maintenance organization; and 10
164	164
165	165	(ii) is furnished through the internal pharmacy operations of the 11
166	166	nonprofit health maintenance organization. 12
167	167
168	168	(q) “Pharmacy benefits manager” means a person that performs pharmacy 13
169	169	benefits management services. 14
170	170
171	171	(r) “Proprietary information” means: 15
172	172
173	173	(1) a trade secret; 16
174	174
175	175	(2) confidential commercial information; or 17
176	176
177	177	(3) confidential financial information. 18
178	178
179	179	(s) (1) “Purchaser” means a person that offers a plan or program in the State, 19
180	180	including the State Employee and Retiree Health and Welfare Benefits Program, AN 20
181	181	INSURER, A NONPROFIT HEALTH S ERVICE PLAN , OR A HEALTH MAIN TENANCE 21
182	182	ORGANIZATION , that: 22
183	183
184	184	[(1)] (I) provides prescription drug coverage or benefits in the State; and 23
185	185
186	186	[(2)] (II) enters into an agreement with a pharmacy benefits manager for 24
187	187	the provision of pharmacy benefits management services. 25
188	188
189	189	(2) “PURCHASER” DOES NOT INCLUDE A N ONPROFIT HEALTH 26
190	190	MAINTENANCE ORGANIZA TION THAT: 27
191	191
192	192	(I) OPERATES AS A GROUP MODEL; 28
193	193	SENATE BILL 303 5
194	194
195	195
196	196	(II) PROVIDES SERVICES SO LELY TO MEMBERS OR P ATIENTS OF 1
197	197	THE NONPROFIT HEALTH MAINTENANCE ORGANIZA TION; AND 2
198	198
199	199	(III) FURNISHES SERVICES T HROUGH THE INTERNAL PHARMACY 3
200	200	OPERATIONS OF THE NO NPROFIT HEALTH MAINT ENANCE ORGANIZATION . 4
201	201
202	202	(t) “Rebate sharing contract” means a contract between a pharmacy benefits 5
203	203	manager and a purchaser under which the pharmacy benefits manager agrees to share 6
204	204	manufacturer payments with the purchaser. 7
205	205
206	206	(u) (1) “Therapeutic interchange” means any change from one prescription 8
207	207	drug to another. 9
208	208
209	209	(2) “Therapeutic interchange” does not include: 10
210	210
211	211	(i) a change initiated pursuant to a drug utilization review; 11
212	212
213	213	(ii) a change initiated for patient safety reasons; 12
214	214
215	215	(iii) a change required due to market unavailability of the currently 13
216	216	prescribed drug; 14
217	217
218	218	(iv) a change from a brand name drug to a generic drug in accordance 15
219	219	with § 12–504 of the Health Occupations Article; or 16
220	220
221	221	(v) a change required for coverage reasons because the originally 17
222	222	prescribed drug is not covered by the beneficiary’s formulary or plan. 18
223	223
224	224	(v) “Therapeutic interchange solicitation” means any communication by a 19
225	225	pharmacy benefits manager for the purpose of requesting a therapeutic interchange. 20
226	226
227	227	(w) “Trade secret” has the meaning stated in § 11–1201 of the Commercial Law 21
228	228	Article. 22
229	229
230	230	15–1611. 23
231	231
232	232	(a) [This section applies only to a pharmacy benefits manager that provides 24
233	233	pharmacy benefits management services on behalf of a carrier. 25
234	234
235	235	(b)] A pharmacy benefits manager may not prohibit a pharmacy or pharmacist 26
236	236	from: 27
237	237
238	238	(1) providing a beneficiary with information regarding the retail price for 28
239	239	a prescription drug or the amount of the cost share for which the beneficiary is responsible 29
240	240	for a prescription drug; 30
241	241	6 SENATE BILL 303
242	242
243	243
244	244	(2) discussing with a beneficiary information regarding the retail price for 1
245	245	a prescription drug or the amount of the cost share for which the beneficiary is responsible 2
246	246	for a prescription drug; or 3
247	247
248	248	(3) if a more affordable drug is available than one on the purchaser’s 4
249	249	formulary and the requirements for a therapeutic interchange under §§ 15–1633.1 through 5
250	250	15–1639 of this subtitle are met, selling the more affordable alternative to the beneficiary. 6
251	251
252	252	[(c)] (B) This section may not be construed to alter the requirements for a 7
253	253	therapeutic interchange under §§ 15–1633.1 through 15–1639 of this subtitle. 8
254	254
255	255	15–1611.1. 9
256	256
257	257	(a) [This section applies only to a pharmacy benefits manager that provides 10
258	258	pharmacy benefits management services on behalf of a carrier. 11
259	259
260	260	(b)] Except as provided in subsection [(c)] (B) of this section, a pharmacy benefits 12
261	261	manager may not require that a beneficiary use a specific pharmacy or entity to fill a 13
262	262	prescription if: 14
263	263
264	264	(1) the pharmacy benefits manager or a corporate affiliate of the pharmacy 15
265	265	benefits manager has an ownership interest in the pharmacy or entity; or 16
266	266
267	267	(2) the pharmacy or entity has an ownership interest in the pharmacy 17
268	268	benefits manager or a corporate affiliate of the pharmacy benefits manager. 18
269	269
270	270	[(c)] (B) A pharmacy benefits manager may require a beneficiary to use a 19
271	271	specific pharmacy or entity for a specialty drug as defined in § 15–847 of this title. 20
272	272
273	273	15–1612. 21
274	274
275	275	(a) [This section applies only to a pharmacy benefits manager that provides 22
276	276	pharmacy benefits management services on behalf of a carrier. 23
277	277
278	278	(b)] This section does not apply to reimbursement: 24
279	279
280	280	(1) for specialty drugs; 25
281	281
282	282	(2) for mail order drugs; or 26
283	283
284	284	(3) to a chain pharmacy with more than 15 stores or a pharmacist who is 27
285	285	an employee of the chain pharmacy. 28
286	286
287	287	[(c)] (B) A pharmacy benefits manager may not reimburse a pharmacy or 29
288	288	pharmacist for a pharmaceutical product or pharmacist service in an amount less than the 30 SENATE BILL 303 7
289	289
290	290
291	291	amount that the pharmacy benefits manager reimburses itself or an affiliate for providing 1
292	292	the same product or service. 2
293	293
294	294	15–1622. 3
295	295
296	296	[(a) Except as provided for in subsection (b) of this section, the provisions of §§ 4
297	297	15–1623 and 15–1624 of this subtitle apply only to a pharmacy benefits manager that 5
298	298	provides pharmacy benefits management services on behalf of a carrier. 6
299	299
300	300	(b)] The provisions of §§ 15–1623 and 15–1624 of this part do not apply to a 7
301	301	pharmacy benefits manager when providing pharmacy benefits management services to a 8
302	302	purchaser that is affiliated with the pharmacy benefits manager through common 9
303	303	ownership within an insurance holding company. 10
304	304
305	305	15–1629. 11
306	306
307	307	(a) [This section applies only to a pharmacy benefits manager that provides 12
308	308	pharmacy benefits management services on behalf of a carrier. 13
309	309
310	310	(b)] This section does not apply to an audit that involves probable or potential 14
311	311	fraud or willful misrepresentation by a pharmacy or pharmacist. 15
312	312
313	313	[(c)] (B) A pharmacy benefits manager shall conduct an audit of a pharmacy or 16
314	314	pharmacist under contract with the pharmacy benefits manager in accordance with this 17
315	315	section. 18
316	316
317	317	[(d)] (C) (1) A pharmacy benefits manager may conduct an audit through an 19
318	318	auditing entity. 20
319	319
320	320	(2) The Commissioner may adopt regulations to carry out this subsection. 21
321	321
322	322	[(e)] (D) A pharmacy benefits manager may not schedule an onsite audit to begin 22
323	323	during the first 5 calendar days of a month unless requested by the pharmacy or 23
324	324	pharmacist. 24
325	325
326	326	[(f)] (E) When conducting an audit, a pharmacy benefits manager shall: 25
327	327
328	328	(1) if the audit is onsite, provide written notice to the pharmacy or 26
329	329	pharmacist at least 2 weeks before conducting the initial onsite audit for each audit cycle; 27
330	330
331	331	(2) employ the services of a pharmacist if the audit requires the clinical or 28
332	332	professional judgment of a pharmacist; 29
333	333
334	334	(3) allow its auditors to enter the prescription area of a pharmacy only 30
335	335	when accompanied by or authorized by a member of the pharmacy staff; 31
336	336	8 SENATE BILL 303
337	337
338	338
339	339	(4) allow a pharmacist or pharmacy to use any prescription, or authorized 1
340	340	change to a prescription, that meets the requirements of COMAR 10.34.20.02 to validate 2
341	341	claims submitted for reimbursement for dispensing of original and refill prescriptions; 3
342	342
343	343	(5) for purposes of validating the pharmacy record with respect to orders 4
344	344	or refills of a drug, allow the pharmacy or pharmacist to use records of a hospital or a 5
345	345	physician or other prescriber authorized by law that are: 6
346	346
347	347	(i) written; or 7
348	348
349	349	(ii) transmitted electronically or by any other means of 8
350	350	communication authorized by contract between the pharmacy and the pharmacy benefits 9
351	351	manager; 10
352	352
353	353	(6) accept a completed cash register transaction to serve as proof of delivery 11
354	354	or pickup for a pharmacy customer unless there is contradictory information; 12
355	355
356	356	(7) audit each pharmacy and pharmacist under the same standards and 13
357	357	parameters as other similarly situated pharmacies or pharmacists audited by the 14
358	358	pharmacy benefits manager; 15
359	359
360	360	(8) only audit claims submitted or adjudicated within the 2–year period 16
361	361	immediately preceding the audit, unless a longer period is authorized under federal or State 17
362	362	law; 18
363	363
364	364	(9) deliver the preliminary audit report to the pharmacy or pharmacist 19
365	365	within 120 calendar days after the completion of the audit, with reasonable extensions 20
366	366	allowed; 21
367	367
368	368	(10) in accordance with subsection [(m)] (L) of this section, allow a 22
369	369	pharmacy or pharmacist to produce documentation to address any discrepancy found 23
370	370	during the audit; and 24
371	371
372	372	(11) deliver the final audit report to the pharmacy or pharmacist: 25
373	373
374	374	(i) within 6 months after delivery of the preliminary audit report if 26
375	375	the pharmacy or pharmacist does not request an internal appeal under subsection [(m)] 27
376	376	(L) of this section; or 28
377	377
378	378	(ii) within 30 days after the conclusion of the internal appeals 29
379	379	process under subsection [(m)] (L) of this section if the pharmacy or pharmacist requests 30
380	380	an internal appeal. 31
381	381
382	382	[(g)] (F) If a contract between a pharmacy or pharmacist and a pharmacy 32
383	383	benefits manager specifies a period of time in which a pharmacy or pharmacist is allowed 33
384	384	to withdraw and resubmit a claim and that period of time expires before the pharmacy 34
385	385	benefits manager delivers a preliminary audit report that identifies discrepancies, the 35 SENATE BILL 303 9
386	386
387	387
388	388	pharmacy benefits manager shall allow the pharmacy or pharmacist to withdraw and 1
389	389	resubmit a claim within 30 days after: 2
390	390
391	391	(1) the preliminary audit report is delivered if the pharmacy or pharmacist 3
392	392	does not request an internal appeal under subsection [(m)] (L) of this section; or 4
393	393
394	394	(2) the conclusion of the internal appeals process under subsection [(m)] 5
395	395	(L) of this section if the pharmacy or pharmacist requests an internal appeal. 6
396	396
397	397	[(h)] (G) During an audit, a pharmacy benefits manager may not disrupt the 7
398	398	provision of services to the customers of a pharmacy. 8
399	399
400	400	[(i)] (H) (1) A pharmacy benefits manager may not: 9
401	401
402	402	(i) use the accounting practice of extrapolation to calculate 10
403	403	overpayments or underpayments; 11
404	404
405	405	(ii) except as provided in paragraph (2) of this subsection: 12
406	406
407	407	1. share information from an audit with another pharmacy 13
408	408	benefits manager; or 14
409	409
410	410	2. use information from an audit conducted by another 15
411	411	pharmacy benefits manager; 16
412	412
413	413	(iii) recoup any funds from or charge any fees to a pharmacy or 17
414	414	pharmacist for a prescription with regard to an incorrect days of supply calculation if the 18
415	415	package size of the medication is unbreakable and the pharmacy benefits manager cannot 19
416	416	accept the correct mathematically calculable days’ supply during prescription adjudication; 20
417	417
418	418	(iv) have or request access to a pharmacy’s or pharmacist’s bank, 21
419	419	credit card, or depository statements or data as it relates to cost–sharing; or 22
420	420
421	421	(v) audit claims that were reversed or for which there was no 23
422	422	remuneration by the purchaser or cost to the pharmacy customer except if necessary to 24
423	423	evaluate compliance to a contract. 25
424	424
425	425	(2) Paragraph (1)(ii) of this subsection does not apply to the sharing of 26
426	426	information: 27
427	427
428	428	(i) required by federal or State law; 28
429	429
430	430	(ii) in connection with an acquisition or merger involving the 29
431	431	pharmacy benefits manager; or 30
432	432
433	433	(iii) at the payor’s request or under the terms of the agreement 31
434	434	between the pharmacy benefits manager and the payor. 32 10 SENATE BILL 303
435	435
436	436
437	437
438	438	[(j)] (I) A pharmacy benefits manager or purchaser may not audit more than 1
439	439	125 prescriptions during a desk or site audit. 2
440	440
441	441	[(k)] (J) The recoupment of a claims payment from a pharmacy or pharmacist 3
442	442	by a pharmacy benefits manager shall be based on an actual overpayment or denial of an 4
443	443	audited claim unless the projected overpayment or denial is part of a settlement agreed to 5
444	444	by the pharmacy or pharmacist. 6
445	445
446	446	[(l)] (K) (1) In this subsection, “overpayment” means a payment by the 7
447	447	pharmacy benefits manager to a pharmacy or pharmacist that is greater than the rate or 8
448	448	terms specified in the contract between the pharmacy or pharmacist and the pharmacy 9
449	449	benefits manager at the time that the payment is made. 10
450	450
451	451	(2) A clerical error, record–keeping error, typographical error, or 11
452	452	scrivener’s error in a required document or record may not constitute fraud or grounds for 12
453	453	recoupment of a claims payment from a pharmacy or pharmacist by a pharmacy benefits 13
454	454	manager if the prescription was otherwise legally dispensed and the claim was otherwise 14
455	455	materially correct. 15
456	456
457	457	(3) Notwithstanding paragraph (2) of this subsection, claims remain 16
458	458	subject to recoupment of overpayment or payment of any discovered underpayment by the 17
459	459	pharmacy benefits manager. 18
460	460
461	461	[(m)] (L) (1) A pharmacy benefits manager shall establish an internal appeals 19
462	462	process under which a pharmacy or pharmacist may appeal any disputed claim in a 20
463	463	preliminary audit report. 21
464	464
465	465	(2) Under the internal appeals process, a pharmacy benefits manager shall 22
466	466	allow a pharmacy or pharmacist to request an internal appeal within 30 working days after 23
467	467	receipt of the preliminary audit report, with reasonable extensions allowed. 24
468	468
469	469	(3) The pharmacy benefits manager shall include in its preliminary audit 25
470	470	report a written explanation of the internal appeals process, including the name, address, 26
471	471	and telephone number of the person to whom an internal appeal should be addressed. 27
472	472
473	473	(4) The decision of the pharmacy benefits manager on an appeal of a 28
474	474	disputed claim in a preliminary audit report by a pharmacy or pharmacist shall be reflected 29
475	475	in the final audit report. 30
476	476
477	477	(5) The pharmacy benefits manager shall deliver the final audit report to 31
478	478	the pharmacy or pharmacist within 30 calendar days after conclusion of the internal 32
479	479	appeals process. 33
480	480
481	481	[(n)] (M) (1) A pharmacy benefits manager may not recoup by setoff any 34
482	482	money for an overpayment or denial of a claim until: 35
483	483	SENATE BILL 303 11
484	484
485	485
486	486	(i) the pharmacy or pharmacist has an opportunity to review the 1
487	487	pharmacy benefits manager’s findings; and 2
488	488
489	489	(ii) if the pharmacy or pharmacist concurs with the pharmacy 3
490	490	benefits manager’s findings of overpayment or denial, 30 working days have elapsed after 4
491	491	the date the final audit report has been delivered to the pharmacy or pharmacist. 5
492	492
493	493	(2) If the pharmacy or pharmacist does not concur with the pharmacy 6
494	494	benefits manager’s findings of overpayment or denial, the pharmacy benefits manager may 7
495	495	not recoup by setoff any money pending the outcome of an appeal under subsection [(m)] 8
496	496	(L) of this section. 9
497	497
498	498	(3) A pharmacy benefits manager shall remit any money due to a pharmacy 10
499	499	or pharmacist as a result of an underpayment of a claim within 30 working days after the 11
500	500	final audit report has been delivered to the pharmacy or pharmacist. 12
501	501
502	502	(4) Notwithstanding the provisions of paragraph (1) of this subsection, a 13
503	503	pharmacy benefits manager may withhold future payments before the date the final audit 14
504	504	report has been delivered to the pharmacy or pharmacist if the identified discrepancy for 15
505	505	all disputed claims in a preliminary audit report for an individual audit exceeds $25,000. 16
506	506
507	507	[(o)] (N) (1) A pharmacy benefits manager shall provide a pharmacy or 17
508	508	pharmacist being audited with a phone number and, if available, access to a secure portal 18
509	509	that the pharmacy or pharmacist may use to ask questions regarding the audit. 19
510	510
511	511	(2) An individual who is familiar with the audit shall respond to all 20
512	512	inquiries made through a phone number or secure portal provided under paragraph (1) of 21
513	513	this subsection within 3 business days after the inquiry was made. 22
514	514
515	515	[(p)] (O) (1) The pharmacy benefits manager shall give the pharmacy or 23
516	516	pharmacist the option to provide requested audit documentation by postal mail, e–mail, or 24
517	517	facsimile. 25
518	518
519	519	(2) If a document is requested regarding an audit, the pharmacy benefits 26
520	520	manager shall provide a secure facsimile number and a mechanism for receiving secure 27
521	521	e–mails. 28
522	522
523	523	(3) On or before October 1, 2025, a pharmacy benefits manager shall 29
524	524	provide a mechanism for secure electronic communication for pharmacies and pharmacists 30
525	525	to communicate with and submit documents to the auditing entity. 31
526	526
527	527	[(q)] (P) (1) The Commissioner may adopt regulations regarding: 32
528	528
529	529	(i) the documentation that may be requested during an audit; and 33
530	530
531	531	(ii) the process a pharmacy benefits manager may use to conduct an 34
532	532	audit. 35 12 SENATE BILL 303
533	533
534	534
535	535
536	536	(2) On request of the Commissioner or the Commissioner’s designee, a 1
537	537	pharmacy benefits manager shall provide a copy of its audit procedures or internal appeals 2
538	538	process. 3
539	539
540	540	15–1630. 4
541	541
542	542	(a) [This section applies only to a pharmacy benefits manager that provides 5
543	543	pharmacy benefits management services on behalf of a carrier. 6
544	544
545	545	(b)] A pharmacy benefits manager shall establish a reasonable internal review 7
546	546	process for a pharmacy to request the review of a failure to pay the contractual 8
547	547	reimbursement amount of a submitted claim. 9
548	548
549	549	[(c)] (B) A pharmacy may request a pharmacy benefits manager to review a 10
550	550	failure to pay the contractual reimbursement amount of a claim within 180 calendar days 11
551	551	after the date the submitted claim was paid by the pharmacy benefits manager. 12
552	552
553	553	[(d)] (C) The pharmacy benefits manager shall give written notice of its review 13
554	554	decision within 90 calendar days after receipt of a request for review from a pharmacy 14
555	555	under this section. 15
556	556
557	557	[(e)] (D) If the pharmacy benefits manager determines through the internal 16
558	558	review process established under subsection [(b)] (A) of this section that the pharmacy 17
559	559	benefits manager underpaid a pharmacy, the pharmacy benefits manager shall pay any 18
560	560	money due to the pharmacy within 30 working days after completion of the internal review 19
561	561	process. 20
562	562
563	563	[(f)] (E) This section may not be construed to limit the ability of a pharmacy and 21
564	564	a pharmacy benefits manager to contractually agree that a pharmacy may have more than 22
565	565	180 calendar days to request an internal review of a failure of the pharmacy benefits 23
566	566	manager to pay the contractual amount of a submitted claim. 24
567	567
568	568	SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 25
569	569	January 1, 2026. 26
570	570
571	571