Chapter 15. Maryland Rx Program
Regulation .01 Purpose.LinkCopy Citation
The purpose of the Maryland Rx Program is to achieve savings for purchasing pool members on the cost of prescription drugs and pharmacy benefit management and administration services through the operation of a purchasing pool.
Regulation .02 Definitions.LinkCopy Citation
A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Department” means the Department of Budget and Management.
(2)
“Director” means the Director of Employee Benefits for the Department of Budget and Management.
(3)
“Local governments” means the counties of Maryland, Baltimore City, municipalities, and quasi-governmental entities, such as cooperative inter-governmental councils and special taxing districts.
(4)
“Maryland Rx Program” means the purchasing pool for pharmacy benefits that is established and operated by the Department of Budget and Management pursuant to State Personnel and Pensions Article, §2-502.1, Annotated Code of Maryland.
(5)
“Member” may include benefits coverage for the participant and for the participant’s dependents, according to the eligibility requirements and plan design of the purchasing pool member.
(6)
“Participant” means an employee or retired employee of a purchasing pool member who is eligible to elect coverage in a purchasing pool member’s prescription benefits plan.
(7)
“Program” means the State Employee and Retiree Health and Welfare Benefits Program administered by the Department.
(8)
“Purchasing pool member” means the entity that participates in the Maryland Rx Program to purchase services in connection with its group prescription benefits plan.
(9)
“Qualifying not-for-profit organization” means an organization described in State Personnel and Pensions Article, §2-512, Annotated Code of Maryland.
(10)
“Secretary” means the Secretary of the Department of Budget and Management, or a designee of the Secretary.
Regulation .03 Eligibility and Application.LinkCopy Citation
A.
Subject to §C of this regulation, entities eligible to participate in the Maryland Rx Program as purchasing pool members are:
(1)
Local governments; and
(2)
Qualifying not-for-profit organizations.
B.
To join the Maryland Rx Program as a purchasing pool member, an entity that meets the requirements of §A of this regulation may submit a statement of interest and a written commitment, executed by an official authorized to bind the entity, to meet the requirements of this chapter to the Department or to the contractor, agent, or representative identified by the Department for management and administration of the Maryland Rx Program.
C.
The determination whether an entity is eligible to be a purchasing pool member shall be made by the Pharmacy Benefits Manager (PBM). The PBM shall provide verifying documentation as requested by the Director for auditing purposes.
D.
An entity who has been determined by the PBM to be ineligible to be a purchasing pool member may appeal the decision to the Director. The appeal shall be submitted in writing to the Director within 30 calendar days of the date of the written denial from the PBM. The Director’s decision is final.
Regulation .04 Purchasing Pool Member Responsibilities.LinkCopy Citation
A.
Each purchasing pool member shall:
(1)
Permit the Department to have access to enrollment information (limited to participant names, Social Security numbers, enrollment tier, and plan design) for purposes of Maryland Rx Program administration, such as general reporting, auditing, and verifying eligibility of the entity as a purchasing pool member;
(2)
Pay all the costs and fees, including but not limited to claims costs, administrative fees, and dispensing fees, associated with its own prescription benefits plan administered as part of the Maryland Rx Program;
(3)
Provide enrollment and eligibility data to the contractor as necessary to administer the pharmacy or prescription benefits plan administered as part of the Maryland Rx Program;
(4)
Negotiate the administrative services to be provided in administering the purchasing pool member's prescription drug plan and the administrative fees paid by the purchasing pool member for those services, the negotiations to be with the Department's contractor, agent, or representative identified by the Department for management and administration of the Maryland Rx Program;
(5)
Commit to participating in the Maryland Rx Program for a full 12 month plan year period at a time; and
(6)
Acknowledge that the purchasing pool member remains the sponsor of the entity's own prescription benefits plan for its employees and is responsible for the administration, legality, and operation of that plan.
B.
Plan Design.
(1)
A purchasing pool member may choose a copayment structure for the plan design of the pharmacy or prescription benefits plan that it shall sponsor and administer as part of the Maryland Rx Program and is not limited by the copayment structure set by the State for the State’s prescription benefits plan operated as part of the Program.
(2)
Except as otherwise provided in this chapter, each purchasing pool member may determine the design of, and who is eligible for, coverage in its own prescription benefits plan.
C.
A purchasing pool member shall set the fully insured equivalent premiums (including employee and employer portion as applicable) for its own self-funded plan and is not limited by premiums and employer contributions set by the State for the State's plan operated as part of the Program.
D.
A purchasing pool member may set the start and end date of its 12 month plan year. Implementation services and schedules may be negotiated between the purchasing pool member and the contractor described in Regulation .06 of this chapter.
Regulation .05 Services Available to Purchasing Pool Members.LinkCopy Citation
A.
A purchasing pool member shall benefit from participation in the Maryland Rx Program as follows:
(1)
Setting the fully insured equivalent premiums (including employee and employer portion as applicable) for its own self-funded plan, without reference to the employer and employee contributions set by the State for the State's prescription benefits plan; and
(2)
Receiving, in exchange for the negotiated administrative fee, the following services in connection with its own pharmacy or prescription benefits plan:
(a)
Account management services;
(b)
Claims payment, processing and tracking services;
(c)
Reporting;
(d)
Enrollment tracking; and
(e)
Invoicing.
B.
The drug ingredient cost and pricing terms, maximum dispensing fees, and minimum rebate guarantees that are associated with the total enrollment in the Maryland Rx Program shall be used to calculate the costs payable by and rebates issued to each purchasing pool member in connection with its prescription benefits plan.
Regulation .06 Department Responsibilities.LinkCopy Citation
A.
The Department shall make available pharmacy or prescription benefit plan management and administration services to purchasing pool members through the Maryland Rx Program by means of a procurement contract with a contractor providing pharmacy or prescription benefit plan management and administration services. The Department may not enter into a contract with a purchasing pool member to provide the benefits and services of the Maryland Rx Program.
B.
Services provided to purchasing pool members shall be by means of a contract between the purchasing pool member and the contractor providing pharmacy or prescription benefit plan management and administration services. The Department's contract with the contractor providing pharmacy or prescription benefit plan management and administration services shall, unless the Department in its discretion makes Maryland Rx Program benefits available to purchasing pool members in another fashion, permit purchasing pool members to purchase pharmacy or prescription benefit plan management and administration services on terms consistent with the requirements of this chapter related to the Maryland Rx Program.
C.
The Department is immune from any liability arising from any dispute between a purchasing pool member and any contractor providing pharmacy or prescription benefit plan management and administration services in connection with the Maryland Rx Program.
Chapter annotations
Authority: State Personnel and Pensions Article, §§2-502.1 and 2-503, Annotated Code of Maryland
History: Effective date: February 23, 2009 (36:4 Md. R. 355)
History: Regulation .02B amended effective October 26, 2015 (42:21 Md. R. 1303)
History: Regulation .03C, D amended effective October 26, 2015 (42:21 Md. R. 1303)
History: Regulation .04A, B amended effective October 26, 2015 (42:21 Md. R. 1303)