<?xml version='1.0' encoding='utf-8'?>
<section article="gin" article_name="Insurance" number="15-1628.2" title_number="15" title_name="Health Insurance" subtitle_number="16" subtitle_name="Pharmacy Benefits Managers">
  <level label="a">
    <text>For disputes regarding cost pricing and reimbursement under a participating pharmacy contract, each participating pharmacy contract must include a process to appeal, investigate, and resolve disputes regarding cost pricing and reimbursement that includes:</text>
    <level label="1">
      <text>a requirement that an appeal be filed by the contract pharmacy not later than 21 days after:</text>
      <level label="i">
        <text>the date a direct or indirect remuneration fee is charged; or</text>
      </level>
      <level label="ii">
        <text>another date as determined by the Commissioner;</text>
      </level>
    </level>
    <level label="2">
      <text>a requirement that a pharmacy benefits manager make available on its website information about the appeal process, including:</text>
      <level label="i">
        <text>a telephone number at which the contracted pharmacy may directly contact the department or office responsible for processing appeals for the pharmacy benefits manager to speak to an individual or leave a message for an individual who is responsible for processing appeals;</text>
      </level>
      <level label="ii">
        <text>an e–mail address of the department or office responsible for processing appeals to which an individual who is responsible for processing appeals has access; and</text>
      </level>
      <level label="iii">
        <text>a notice indicating that the individual responsible for processing appeals shall return a call or an e–mail made by a contracted pharmacy to the individual within 3 business days or less after receiving the call or e–mail;</text>
      </level>
    </level>
    <level label="3">
      <text>a requirement that a pharmacy benefits manager provide:</text>
      <level label="i">
        <text>a reason for any appeal denial; and</text>
      </level>
      <level label="ii">
        <text>the mathematical calculation used to determine the amount of reimbursement; and</text>
      </level>
    </level>
    <level label="4">
      <text>if an appeal is upheld, a requirement that a pharmacy benefits manager:</text>
      <level label="i">
        <text>make adjustments as necessary to comply with the compensation program as stated in the participating pharmacy contract as of the date the appeal was determined; and</text>
      </level>
      <level label="ii">
        <text>provide notice to the pharmacy or pharmacy’s contracted agent that an appeal has been upheld.</text>
      </level>
    </level>
  </level>
  <level label="b">
    <text>A pharmacy benefits manager may not retaliate against a contracted pharmacy for exercising its right to appeal under this section or filing a complaint with the Commissioner under this section.</text>
  </level>
  <level label="c">
    <text>A pharmacy benefits manager may not charge a contracted pharmacy a fee related to the readjudication of a claim or claims resulting from the upholding of an appeal under subsection (d) of this section.</text>
  </level>
  <level label="d">
    <level label="1">
      <text>If a pharmacy benefits manager denies an appeal and a contracted pharmacy or a designee of the contracted pharmacy files a complaint with the Commissioner, the Commissioner shall:</text>
      <level label="i">
        <text>review the compensation program of the pharmacy benefits manager to ensure that the reimbursement for pharmacy services paid to the pharmacist or a pharmacy complies with this subtitle and the terms of the participating pharmacy contract; and</text>
      </level>
      <level label="ii">
        <text>based on a determination made by the Commissioner under item (i) of this paragraph, dismiss the appeal or uphold the appeal and order the pharmacy benefits manager to pay the claim or claims in accordance with the Commissioner’s findings.</text>
      </level>
    </level>
    <level label="2">
      <text>On request, the pharmacy benefits manager shall provide to the Commissioner all mathematical calculations, accounts, records, documents, files, logs, correspondence, or other information necessary to complete the Commissioner’s review.</text>
    </level>
    <level label="3">
      <text>All information and data collected by the Commissioner during a review:</text>
      <level label="i">
        <text>is considered to be confidential and proprietary information; and</text>
      </level>
      <level label="ii">
        <text>is not subject to disclosure under the Public Information Act.</text>
      </level>
    </level>
  </level>
</section>
