An Act To Restore Market-based Competition for Pharmacy Benefits Management Services
Maine Legislature, Session 125, LD 1116
Committee Amendment CA_A_H608 (House)
Amends: 24-A MRSA §4317

COMMITTEE AMENDMENT "A" to H.P. 828, L.D. 1116, Bill, "An Act To 
Restore Market-based Competition for Pharmacy Benefits Management Services" 
Amend the bill by inserting after section 4 the following: 
'Sec. 5. 24-A MRSA §4317, sub-§3, as enacted by PL 2009, c. 519, §l and 
affected by §2, is amended to read: 
3. Exception. This seetion does Subsections 1 and 2 do 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-D. 
Sec. 6. 24-A MRS A §4317, sub-§§4 to 11 is enacted to read: 
4. Participation in contracts. A pharmacy benefits manager may not require a 
pharmacist or pharmacy to participate in one network in order to participate in another 
network. The pharmacy benefits manager may not exclude an otherwise qualified 
pharmacist or pharmacy from participation in one network solely because the pharmacist 
or pharmacy declined to participate in another network managed by the pharmacy 
benefits manager. 
5. Prohibition. The written contract between a carrier and a pharmacy benefits 
manager may not provide that the pharmacist or pharmacy is responsible for the actions 
of the insurer or a pharmacy benefits manager. 
6. Pharmacy benefits manager duties. All contracts must provide that, when the 
pharmacy benefits manager receives payment for the services of a pharmacist or 
pharmacy, the pharmacy benefits manager shall distribute the funds in accordance with 
the time frames provided in Title 22, section 2699-A. 
7. Complaints, grievances and appeals. A pharmacy benefits manager may not 
terminate the contract of or penalize a pharmacist or pharmacy solely as a result of the 
pharmacist's or pharmacy's filing of a complaint, grievance or appeal. This subsection is 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT·A" to H.P. 828, L.D. 1116 
not intended to restrict the pharmacy's and pharmacy benefits manager's ability to enter 
into agreements that allow for mutual termination without cause. 
8. 
Denial or limitation of benefits. A pharmacy's benefits manager may not 
terminate the contract of or penalize a pharmacist or pharmacy for expressing 
disagreement with a carrier's decision to deny or limit benefits to an enrollee or because 
the pharmacist or pharmacy assists the enrollee to seek reconsideration of the carrier's 
decision or because the pharmacist or pharmacy discusses alternative medications. 
9. Written notice required. At least 60 days before a pharmacy's benefits manager 
terminates a pharmacy's or pharmacist's participation in the pharmacy benefits manager's 
plan or network, the pharmacy benefits manager shall give the pharmacy or pharmacist a 
written explanation of the reason for the termination, unless the termination is based on: 
A. 
The loss of the pharmacy's license or the pharmacist'S license to practice 
pharmacy or cancellation of professional liability insurance: or 
B. A finding of fraud. 
At least 60 days before a pharmacy or pharmacist terminates its participation in a 
pharmacy benefits manager's plan or network, the pharmacy or pharmacist shall give the 
pharmacy benefits manager a written explanation of the reason for the termination. 
10. Audits. Notwithstanding any other provision of law, when an on-site audit of 
the records of a pharmacy is conducted by a pharmacy benefits manager, the audit must 
be conducted in accordance with the following criteria. 
A. 
A finding of overpayment or underpayment must be based on the actual 
overpayment or underpayment and not a projection based on the number of patients 
served having a similar diagnosis or on the number of similar orders or refills for 
similar drugs, unless the projected overpayment or denial is a part of a settlement 
agreed to by the pharmacy or pharmacist. 
B. The auditor may not use extrapolation in calculating recoupments or penalties. 
C. Any audit that involves clinical or professional judgment must be conducted by or 
in consultation with a pharmacist. 
D. Each entity conducting an audit shall establish an appeals process under which a 
pharmacy may appeal an unfavorable preliminary audit report to the entity. 
E. 
This subsection does not apply to any audit, review or investigation that is 
initiated based on or involves suspected or alleged fraud, willful misrepresentation or 
abuse. 
11. Audit information and reports. A preliminary audit report must be delivered 
to the pharmacy within 60 days after the conclusion of the audit under subsection 10. A 
pharmacy must be allowed at least 30 days following receipt of the preliminary audit to 
provide documentation to address any discrepancy found in the audit. A final audit report 
must be delivered to the pharmacy within 90 days after receipt of the preliminary audit 
report or final appeal, whichever is later. A charge-back, recoupment or other penalty 
may not be assessed until the appeal process provided by the pharmacy benefits manager 
has been exhausted and the final report issued. Except as provided by state or federal 
COMMITTEE AMENDMENT 
\ 
COMMITTEE AMENDMENT 'A "to H.P. 828, L.D. 1116 
law, audit information may not be shared. Auditors may have access only to previous 
audit reports on a particular pharmacy conducted by that same entity.' 
Amend the bill by relettering or renumbering any nonconsecutive Part letter or 
section number to read consecutively. 
SUMMARY 
This amendment is the majority report of the committee. This amendment adds to the 
bill provisions that relate to the business relationship between a pharmacy and a 
pharmacy benefits manager. The provisions address the contract between the 2 entities, 
pharmacy benefits manager duties, complaints, grievances and appeals, denial or 
limitation of benefits, written notice and audits of the records of the pharmacy. 
FISCAL ~OTE REQt.:lRED 
(See att.~c.~~~)_ 
COMMITTEE AMENDMENT 
Approved: 06/09111 hac 
LD 1116 
LR 1589(02) 
An Act To Restore Market-based Competition for Pharmacy Benefits Management Services 
Fiscal Detail and Notes 
Fiscal Note for Bill as Amended by Committee Amendment "A" 
Committee: Health and Human Services 
Fiscal Note Required: Yes 
Fiscal Note 
Potential current biennium cost impact - General Fund 
Minor cost increase - Other Special Revenue Funds 
The fiscal impact to the Department of Corrections will depend on negotiated costs and can not be determined at this 
time. Any additional costs to the Bureau ofInsurance in the Department of Professional and Financial Regulation are 
expected to be minor and can be absorbed within existing budgeted resources. 
LR1589(02) - Fiscal Note - Page 1 of 1