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<section article="gin" article_name="Insurance" number="15-1601" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers">
  <level label="a">
    <text>In this subtitle the following words have the meanings indicated.</text>
  </level>
  <level label="b">
    <text>“Agent” means a pharmacy, a pharmacist, a mail order pharmacy, or a nonresident pharmacy acting on behalf or at the direction of a pharmacy benefits manager.</text>
  </level>
  <level label="c">
    <text>“Beneficiary” means an individual who receives prescription drug coverage or benefits from a purchaser.</text>
  </level>
  <level label="d">
    <level label="1">
      <text>“Carrier” means the State Employee and Retiree Health and Welfare Benefits Program, an insurer, a nonprofit health service plan, or a health maintenance organization that:</text>
      <level label="i">
        <text>provides prescription drug coverage or benefits in the State; and</text>
      </level>
      <level label="ii">
        <text>enters into an agreement with a pharmacy benefits manager for the provision of pharmacy benefits management services.</text>
      </level>
    </level>
    <level label="2">
      <text>“Carrier” does not include a person that provides prescription drug coverage or benefits through plans subject to ERISA and does not provide prescription drug coverage or benefits through insurance, unless the person is a multiple employer welfare arrangement as defined in § 514(b)(6)(a)(ii) of ERISA.</text>
    </level>
  </level>
  <level label="e">
    <text>“Compensation program” means a program, policy, or process through which sources and pricing information are used by a pharmacy benefits manager to determine the terms of payment as stated in a participating pharmacy contract.</text>
  </level>
  <level label="f">
    <text>“Contracted pharmacy” means a pharmacy that participates in the network of a pharmacy benefits manager through a contract with:</text>
    <level label="1">
      <text>the pharmacy benefits manager; or</text>
    </level>
    <level label="2">
      <text>a pharmacy services administration organization or a group purchasing organization.</text>
    </level>
  </level>
  <level label="g">
    <text>“ERISA” has the meaning stated in § 8–301 of this article.</text>
  </level>
  <level label="h">
    <text>“Formulary” means a list of prescription drugs used by a purchaser.</text>
  </level>
  <level label="i">
    <level label="1">
      <text>“Manufacturer payments” means any compensation or remuneration a pharmacy benefits manager receives from or on behalf of a pharmaceutical manufacturer.</text>
    </level>
    <level label="2">
      <text>“Manufacturer payments” includes:</text>
      <level label="i">
        <text>payments received in accordance with agreements with pharmaceutical manufacturers for formulary placement and, if applicable, drug utilization;</text>
      </level>
      <level label="ii">
        <text>rebates, regardless of how categorized;</text>
      </level>
      <level label="iii">
        <text>market share incentives;</text>
      </level>
      <level label="iv">
        <text>commissions;</text>
      </level>
      <level label="v">
        <text>fees under products and services agreements;</text>
      </level>
      <level label="vi">
        <text>any fees received for the sale of utilization data to a pharmaceutical manufacturer; and</text>
      </level>
      <level label="vii">
        <text>administrative or management fees.</text>
      </level>
    </level>
    <level label="3">
      <text>“Manufacturer payments” does not include purchase discounts based on invoiced purchase terms.</text>
    </level>
  </level>
  <level label="j">
    <text>“Nonprofit health maintenance organization” has the meaning stated in § 6–121(a) of this article.</text>
  </level>
  <level label="k">
    <text>“Nonresident pharmacy” has the meaning stated in § 12–403 of the Health Occupations Article.</text>
  </level>
  <level label="l">
    <text>“Participating pharmacy contract” means a contract filed with the Commissioner in accordance with § 15–1628(b) of this subtitle.</text>
  </level>
  <level label="m">
    <text>“Pharmacist” has the meaning stated in § 12–101 of the Health Occupations Article.</text>
  </level>
  <level label="n">
    <text>“Pharmacy” has the meaning stated in § 12–101 of the Health Occupations Article.</text>
  </level>
  <level label="o">
    <text>“Pharmacy and therapeutics committee” means a committee established by a pharmacy benefits manager to:</text>
    <level label="1">
      <text>objectively appraise and evaluate prescription drugs; and</text>
    </level>
    <level label="2">
      <text>make recommendations to a purchaser regarding the selection of drugs for the purchaser’s formulary.</text>
    </level>
  </level>
  <level label="p">
    <level label="1">
      <text>“Pharmacy benefits management services” means:</text>
      <level label="i">
        <text>the procurement of prescription drugs at a negotiated rate for dispensation within the State to beneficiaries;</text>
      </level>
      <level label="ii">
        <text>the administration or management of prescription drug coverage provided by a purchaser for beneficiaries; and</text>
      </level>
      <level label="iii">
        <text>any of the following services provided with regard to the administration of prescription drug coverage:</text>
        <level label="1">
          <text>mail service pharmacy;</text>
        </level>
        <level label="2">
          <text>claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to beneficiaries;</text>
        </level>
        <level label="3">
          <text>clinical formulary development and management services;</text>
        </level>
        <level label="4">
          <text>rebate contracting and administration;</text>
        </level>
        <level label="5">
          <text>patient compliance, therapeutic intervention, and generic substitution programs; or</text>
        </level>
        <level label="6">
          <text>disease management programs.</text>
        </level>
      </level>
    </level>
    <level label="2">
      <text>“Pharmacy benefits management services” does not include any service provided by a nonprofit health maintenance organization that operates as a group model, provided that the service:</text>
      <level label="i">
        <text>is provided solely to a member of the nonprofit health maintenance organization; and</text>
      </level>
      <level label="ii">
        <text>is furnished through the internal pharmacy operations of the nonprofit health maintenance organization.</text>
      </level>
    </level>
  </level>
  <level label="q">
    <text>“Pharmacy benefits manager” means a person that performs pharmacy benefits management services.</text>
  </level>
  <level label="r">
    <text>“Proprietary information” means:</text>
    <level label="1">
      <text>a trade secret;</text>
    </level>
    <level label="2">
      <text>confidential commercial information; or</text>
    </level>
    <level label="3">
      <text>confidential financial information.</text>
    </level>
  </level>
  <level label="s">
    <text>“Purchaser” means a person that offers a plan or program in the State, including the State Employee and Retiree Health and Welfare Benefits Program, that:</text>
    <level label="1">
      <text>provides prescription drug coverage or benefits in the State; and</text>
    </level>
    <level label="2">
      <text>enters into an agreement with a pharmacy benefits manager for the provision of pharmacy benefits management services.</text>
    </level>
  </level>
  <level label="t">
    <text>“Rebate sharing contract” means a contract between a pharmacy benefits manager and a purchaser under which the pharmacy benefits manager agrees to share manufacturer payments with the purchaser.</text>
  </level>
  <level label="u">
    <level label="1">
      <text>“Therapeutic interchange” means any change from one prescription drug to another.</text>
    </level>
    <level label="2">
      <text>“Therapeutic interchange” does not include:</text>
      <level label="i">
        <text>a change initiated pursuant to a drug utilization review;</text>
      </level>
      <level label="ii">
        <text>a change initiated for patient safety reasons;</text>
      </level>
      <level label="iii">
        <text>a change required due to market unavailability of the currently prescribed drug;</text>
      </level>
      <level label="iv">
        <text>a change from a brand name drug to a generic drug in accordance with § 12–504 of the Health Occupations Article; or</text>
      </level>
      <level label="v">
        <text>a change required for coverage reasons because the originally prescribed drug is not covered by the beneficiary’s formulary or plan.</text>
      </level>
    </level>
  </level>
  <level label="v">
    <text>“Therapeutic interchange solicitation” means any communication by a pharmacy benefits manager for the purpose of requesting a therapeutic interchange.</text>
  </level>
  <level label="w">
    <text>“Trade secret” has the meaning stated in § 11–1201 of the Commercial Law Article.</text>
  </level>
</section>
