An Act To Adopt a Drug Benefit Equity Law . Amend the bill by striking out everything after the enacting clause and before the summary and inserting the following: Sec. 1. 24-A MRS A §4317 is enacted to read: §4317. Pharmacy provider's 1. Contracts with pharmacy pr·ovider's. Notwithstanding section 2672, section 4307, subsection 3 and Title 32, chapter 117, subchapter 8, a carrier that provides coverage for prescription drugs as part of a health plan may not refuse to contract with a pharmacy provider that is qualified and is willing to meet the terms and conditions of the carrier's criteria for pharmacy participation as stipulated in the carrier's contractual agreement with its pharmacy providers. This subsection may not be construed to limit a carrier's ability to offer an enrollee incentives, including variations in premiums, deductibles, copayments or coinsurance or variations in the quantities of medications available to the enrollee, to encourage the use of certain preferred pharmacy providers as long as the carrier makes the terms applicable to the preferred pharmacy providers available to all pharmacy providers. For purposes of this subsection, a preferred pharmacy provider is any pharmacy willing to meet the specified terms, conditions and price that the carrier may require. for its preferred pharmacy providers. 2. Prompt payment of claims. Notwithstanding section 2436, the following provisions apply to the payment of claims submitted to a carrier by a pharmacy provider. A. For purposes of this subsection, the following terms have the following meanings. (1) "Applicable number of calendar days" means: Ca) With respect to claims submitted electronically, 21 days; and Cb) With respect to claims submitted otherwise, 30 days. Page I - 124LR2492(02)-1 COMMITTEE AMENDMENT
Maine Legislature, Session 124, LD 1498
Committee Amendment CA_A_S374 (Senate)

COMMITTEE AMENDMENT" It " to S.P. 576, L.D. 1498, Bill, "An Act To 
Adopt a Drug Benefit Equity Law" 
. Amend the bill by striking out everything after the enacting clause and before the 
summary and inserting the following: 
'Sec. 1. 24-A MRS A §4317 is enacted to read: 
§4317. Pharmacy provider's 
1. Contracts with pharmacy pr·ovider's. Notwithstanding section 2672, section 
4307, subsection 3 and Title 32, chapter 117, subchapter 8, a carrier that provides 
coverage for prescription drugs as part of a health plan may not refuse to contract with a 
pharmacy provider that is qualified and is willing to meet the terms and conditions of the 
carrier's criteria for pharmacy participation as stipulated in the carrier's contractual 
agreement with its pharmacy providers. 
This subsection may not be construed to limit a carrier's ability to offer an enrollee 
incentives, including variations in premiums, deductibles, copayments or coinsurance or 
variations in the quantities of medications available to the enrollee, to encourage the use 
of certain preferred pharmacy providers as long as the carrier makes the terms applicable 
to the preferred pharmacy providers available to all pharmacy providers. For purposes of 
this subsection, a preferred pharmacy provider is any pharmacy willing to meet the 
specified terms, conditions and price that the carrier may require. for its preferred 
pharmacy providers. 
2. 
Prompt payment of claims. Notwithstanding section 2436, the following 
provisions apply to the payment of claims submitted to a carrier by a pharmacy provider. 
A. For purposes of this subsection, the following terms have the following meanings. 
(1) "Applicable number of calendar days" means: 
Ca) With respect to claims submitted electronically, 21 days; and 
Cb) With respect to claims submitted otherwise, 30 days. 
Page I - 124LR2492(02)-1 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT" A" to S.P. 576, L.D. 1498 
(2) "Clean claim" means a claim that has no defect or impropriety, including any 
lack of any required substantiating documentation, or particular circumstance 
requiring special treatment that prevents timely payment from being made on the 
claim under this section. 
B. A contract entered into by a calTier with a pharmacy provider with respect to a 
prescription drug plan offered by a can'ier must provide that payment is issued, 
mailed or otherwise transmitted with respect to all clean claims submitted by a 
pharmacy provider, other than a pharmacy that dispenses drugs by mail order only or 
a pharmacy located in, or under contract with, a long-term care facility, within the 
applicable number of calendar days after the date on which the claim is received. For 
purposes of this subsection, a claim is considered to have been received: 
(I) With respect to claims submitted electronically, on the date on which the 
claim is transferred; and 
(2) With respect to claims submitted otherwise, on the 5th day after the postmark 
date of the claim or the date specified in the time stamp' of the transmission of the 
cla~m. 
C. If payment is not issued, mailed or otherwise transmitted by the carrier within the 
~pplicable number of calendar days after a clean claim is received, the carrier shall 
pay interest to the p'harmacy provider at the rate of 18% per annum. 
D. A claim is considered to be a clean claim if the carrier involved does not provide 
notice to the pharmacy provider of any deficiency in the claim within 10 days after 
the date on which an electronically submitted claim is received or within 15 days 
after the date on which a claim submitted otherwise is received, 
E. If a carrier determines that a submitted claim is not a clean claim, the carrier shall 
immediately notifr the pharmacy provider of the detemination. The notice must 
specify all defects or improprieties in the claim and list 'all additional information or 
documents necessary for the proper processing and payment of the claim. If a 
pharmacy provider receives notice from a carrier that a claim has been determined to 
not be a clean claim, the pharmacy provider shall take steps to correct that claim and 
then resubmit the claim to the carrier for payment. 
' 
F. A claim resubmitted to a carrier with additional information pursuant to paragraph 
E is considered to be a clean claim if the carrier does not provide notice to the 
pharmacy provider of any defect or impropriety in the claim within' 10 days of the 
date on which additional information is received if the claim is resubmitted 
electronically or within 15 days of the date on which additional information is 
received if the claim is resubmitted otherwise. 
G. A claim submitted to a carrier that is not paid by the carrier or contested by the 
plan sponsor within the applicable number of calendar days after the date on which 
the claim is received by the carrier is considered to be a clean claim and must be paid 
by the carrier. 
H. Payment of a clean claim under this subsection is considered to have been made 
on the date on which the payment is transferred with respect to claims paid 
COMMITTEE AMENDMENT 
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COMMIITEE AMENDMENT" A 
n to S.P. 576, L.D. 1498 
electronically and on the date on which the payment is submitted to the United States 
Postal Service or common carrier for delivery with respect to claims paid otherwise. 
I. A carrier shall pay all clean claims submitted electronically by electronic transfer. 
of funds if the pharmacy provider so requests or has so requested previously. In the 
case when the payment is made electronically, remittance may be made by the carrier 
electronically; 
3. Exception. This section does not apply to any medical assistance or public health 
programs administered by the Department of Health and Human Services, including, but 
not limited to, the Medicaid program and the elderly low-cost drug program under Title 
22, section 254-0. 
Sec. 2. Application. This Act applies to all policies, contracts and certificates 
executed, delivered, issued for delivery, continued or renewed in this State on or after the 
effective date of this Act.. For purposes of this Act, all contracts are deemed to be 
renewed no later than the next yearly anniversary of the contract date.' 
SUMMARY 
This amendment replaces the bill. The amendment prohibjts a carrier from refusing to 
contract with a pharmacy provider that meets the terms and conditions established by the 
carrier. The amendment clarifies that a carrier may offer enrollees incentives to 
encourage the use of certain preferred pharmacy providers as long as the carrier makes 
the same terms applicable to preferred pharmacy providers available to all pharmacy 
providers. The amendment also requires a carrier to pay all clean electronic claims within 
days after the claim is received by the carrier. 
COMMITTEE AMENDMENT