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<regulation prefix="Regulation" num=".02" citation="COMAR 31.10.47.02" title_num="31" subtitle_num="10" chapter_num="47" heading="Definitions.">
  <paragraph num="A.">
    <text>In this chapter, the following terms have the meanings indicated.</text>
  </paragraph>
  <paragraph num="B.">
    <text>Terms Defined.</text>
    <paragraph num="(1)">
      <text>“Appeal decision” means a written or electronic notice in response to an appeal under this chapter provided to a contracted pharmacy that includes a reason for the appeal denial.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>“Beneficiary” means an individual who receives prescription drug coverage or benefits from a purchaser.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>“Carrier” has the meaning stated in Insurance Article, §15-1601, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(4)">
      <text>“Compensation program” has the meaning stated in Insurance Article, §15-1601, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(5)">
      <text>“Complaint” means a communication by a contracted pharmacy that disputes the appeal decision, and is submitted on a complaint form to the Commissioner, after the pharmacy benefits manager’s internal appeal process has been exhausted as required by Insurance Article, §15-1628.2, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(6)">
      <text>“Complaint form” means the form developed by the Commissioner under Regulation .05 of this chapter.</text>
    </paragraph>
    <paragraph num="(7)">
      <text>“Contracted pharmacy” has the meaning stated in Insurance Article, §15-1601, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(8)">
      <text>“Direct or indirect remuneration fee” means an adjustment in total compensation received directly or indirectly by a contracted pharmacy from a PBM that is determined after the sale of the product or service, including an adjustment of an adjudicated claim based on the use of a generic effective rate or fee or performance-based reimbursement.</text>
    </paragraph>
    <paragraph num="(9)">
      <text>“Participating pharmacy contract” means a contract filed with the Commissioner that is:</text>
      <paragraph num="(a)">
        <text>Between a pharmacy and a:</text>
        <paragraph num="(i)">
          <text>Pharmacy benefits manager;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Pharmacy services administrative organization; or</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>Group purchasing organization;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>Filed as required by the Commissioner;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Not disapproved by the Commissioner; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>In compliance with the requirements stated in this chapter.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(10)">
      <text>“Pharmacist” has the meaning stated in Health Occupations Article, §12–101, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(11)">
      <text>“Pharmacy” has the meaning stated in Health Occupations Article, §12–101, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(12)">
      <text>“Pharmacy benefits management services” has the meaning stated in Insurance Article, §15-1601, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(13)">
      <text>“Pharmacy benefits manager” or “PBM” has the meaning stated in Insurance Article, §15-1601, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(14)">
      <text>“Pharmacy services administration organization” or “PSAO” means an entity that provides a contracted pharmacy with contracting administrative services relating to prescription drug benefits.</text>
    </paragraph>
    <paragraph num="(15)">
      <text>“Pricing information” means anything used in the mathematical calculation to determine the payment to a contracted pharmacy.</text>
    </paragraph>
    <paragraph num="(16)">
      <text>“Purchaser” has the meaning stated in Insurance Article, §15-1601, Annotated Code of Maryland.</text>
    </paragraph>
    <paragraph num="(17)">
      <text>Review Decision.</text>
      <paragraph num="(a)">
        <text>“Review decision” means a written or electronic notice in response to a request from a contracted pharmacy for a review of a failure to pay the contractual reimbursement amount of a submitted claim.</text>
      </paragraph>
      <paragraph num="(b)">
        <text>“Review decision” does not include an appeal decision.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(18)">
      <text>“Source” means the publisher or publishers stated in the participating pharmacy contract, used by the PBM, in any manner, to establish the basis of the PBM’s pricing or the reimbursement amount to a contracted pharmacy, under a participating pharmacy contract’s stated compensation program.</text>
    </paragraph>
    <paragraph num="(19)">
      <text>“Working day” means any day that the Maryland Insurance Administration is open for business.</text>
    </paragraph>
  </paragraph>
</regulation>