<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".05" citation="COMAR 31.11.12.05" title_num="31" subtitle_num="11" chapter_num="12" heading="Uniform Cost-Sharing Arrangements Specific Services.">
  <paragraph num="A.">
    <text>Preferred Provider—Credit Fund Delivery System.</text>
    <paragraph num="(1)">
      <text>Coverage of Category I Services.</text>
      <paragraph num="(a)">
        <text>Except for services listed in Regulation .03A(15), (17), (18), (22), (25), and (34) of this chapter, Category I services shall be covered as follows:</text>
        <paragraph num="(i)">
          <text>Payment for covered services by the fund;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>After exhaustion of the fund and after meeting the deductible requirement as described in Regulation .04B(3) of this chapter, coinsurance requirements as described in Regulation .04B(4) of this chapter.</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>In addition to the deductible and coinsurance requirements specified in §A(1)(a)(ii) of this regulation, services listed in Regulation .03A(17) and (18) of this chapter are subject to a combined benefit maximum of $1,000 per person per contract year.</text>
      </paragraph>
      <paragraph num="(c)">
        <text>In addition to the deductible and coinsurance requirements specified in §A(1)(a)(ii) of this regulation, services listed in Regulation .03A(15), (22), (25), and (34) of this chapter are subject to a benefit maximum of $1,000 per person per contract year.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Coverage of Category II Services.</text>
      <paragraph num="(a)">
        <text>Except for emergency services, Category II services shall be covered by meeting the deductible requirement as described in Regulation .04B(3) of this chapter and coinsurance requirements as described in Regulation .04B(4) of this chapter.</text>
      </paragraph>
      <paragraph num="(b)">
        <text>After meeting the deductible requirement as described in Regulation .04B(3) of this chapter, emergency services shall be subject to a $100 copay in addition to the coinsurance requirements as described in Regulation .04B(4) of this chapter.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>Coverage of Category III Services.</text>
      <paragraph num="(a)">
        <text>Except as required in §A(3)(d) of this regulation, each covered person shall pay the lesser of the cost of the prescription or a copayment of $15.</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Coverage for brand name drugs covered through a pharmacy discount card shall require coinsurance by the covered person of 100 percent of the discounted rate.</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Category III services for generic drugs shall be subject to a $500 benefit maximum per contract year for each covered person.</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Each covered person shall pay the lesser of the cost of the prescription or a $30 copayment for a 90-day supply of generic maintenance drugs dispensed in a single dispensing of a prescription.</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Coverage of up to a 90-day supply of maintenance drugs in a single dispensing is not required for the first prescription of a maintenance drug or a change in a prescription of a maintenance drug.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Preferred Provider—Capped Benefit Delivery System.</text>
    <paragraph num="(1)">
      <text>Group A services are divided into the following services categories:</text>
      <paragraph num="(a)">
        <text>Physician and other health care practitioner office visits (non-preventive services);</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Physician and other health care practitioner office visits (preventive services);</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Equipment and supplies;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Inpatient physician and other non-facility services; and</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Outpatient physician and other health care practitioner services.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>The following benefit maximums apply to the Group A service category indicated:</text>
      <paragraph num="(a)">
        <text>$200 per covered person per contract year for physician and other health care practitioner office visits (nonpreventive services), as listed in Regulation .03A(1), (17), (18), (20), (23), (24), and (29) of this chapter;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>$150 per covered person per contract year for physician and other health care practitioner office visits (preventive services), as listed in Regulation .03A(9)—(12), (31), (33), and (35) of this chapter;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>$250 per covered person per contract year for equipment and supplies, as listed in Regulation .03A(15), (22), (25), and (34) of this chapter;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>$700 per covered person per contract year for inpatient physician and other nonfacility services, as listed in Regulation .03A(2)(a), (4)(a), (7)(a), (13), (14)(a), (19)(a), (21)(a), (26)(a), (28)(a), and (30)(a) of this chapter; and</text>
      </paragraph>
      <paragraph num="(e)">
        <text>$500 per covered person per contract year for outpatient physician and other health care practitioner services, as listed in Regulation .03A(3)(a) and (5)(a) of this chapter.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>The following benefit maximums apply to the Group B service category indicated:</text>
      <paragraph num="(a)">
        <text>$200 per covered person per contract year for emergency and ambulance services, as listed in Regulations .03A(6) and (8) of this chapter; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>$150 per covered person per contract year for outpatient laboratory and diagnostic services, as listed in Regulation .03A(16) of this chapter.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Services covered under Group F shall be covered as follows:</text>
      <paragraph num="(a)">
        <text>Except as required in §B(4)(b) of this regulation, each covered person shall pay the lesser of the cost of the prescription or a copayment of:</text>
        <paragraph num="(i)">
          <text>$10 for generic drugs;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>$30 for preferred brand-name drugs; or</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>$50 for nonpreferred brand-name drugs;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>Each covered person shall pay the lesser of the cost of the prescription or a copayment for a 90-day supply of maintenance drugs dispensed in a single dispensing of a prescription as follows:</text>
        <paragraph num="(i)">
          <text>For generic maintenance drugs, one $20 copayment;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>For preferred brand-name maintenance drugs, one $60 copayment; or</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>For nonpreferred brand-name maintenance drugs, one $100 copayment;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(c)">
        <text>Coverage of up to a 90-day supply of maintenance drugs in a single dispensing is not required for the first prescription of a maintenance drug or a change in a prescription of a maintenance drug; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Services covered in Group F shall be subject to a maximum benefit per contract year of:</text>
        <paragraph num="(i)">
          <text>$250 for a person enrolled under individual coverage; and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>$750 for a person enrolled under other than individual coverage.</text>
        </paragraph>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>