An Act Concerning Pricing Disclosure Requirements and Oversight of Pharmacy Benefits Managers
Maine Legislature, Session 126, LD 1624
Committee: Labor, Commerce, Research and Economic Development
Sponsors: BECK, COOPER, GILBERT, LONGSTAFF, NADEAU, RANKIN, THERIAULT, TREAT
Amends: 22 MRSA §1711-E, 22 MRSA §8702, 22 MRSA §8706, 24-A MRSA §601, 24-A MRSA §1913, 24-A MRSA §4317, 32 MRSA §13800

Legislative Document 
No. 1624 
H.P. 1196 
House of Representatives, December 30, 2013 
An Act Concerning Pricing Disclosure Requirements and Oversight 
of Pharmacy Benefits Managers 
Approved for introduction by a majority of the Legislative Council pursuant to Joint Rule 
203. 
Received by the Clerk of the House on December 23, 2013.  Referred to the Committee on 
Labor, Commerce, Research and Economic Development pursuant to Joint Rule 308.2 and 
ordered printed pursuant to Joint Rule 401. 
MILLICENT M. MacFARLAND 
Clerk 
Presented by Representative BECK of Waterville. 
Cosponsored by Representatives: COOPER of Yarmouth, GILBERT of Jay, LONGSTAFF of 
Waterville, NADEAU of Winslow, RANKIN of Hiram, THERIAULT of Madawaska, TREAT 
of Hallowell. 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1.  22 MRSA §1711-E, sub-§1, ¶G, as amended by PL 2011, c. 443, §1, is 
further amended to read: 
G.  "Pharmacy benefits manager" has the same meaning as in Title 24-A 32, section 
1913 13800, subsection 1, paragraph A C. 
Sec. 2.  22 MRSA §8702, sub-§8-B, as amended by PL 2011, c. 443, §3, is 
further amended to read: 
8-B.  Pharmacy benefits manager.  "Pharmacy benefits manager" has the same 
meaning as in Title 24-A 32, section 1913 13800, subsection 1, paragraph A C. 
Sec. 3.  22 MRSA §8706, sub-§2, ¶C, as amended by PL 2007, c. 136, §5, is 
further amended to read: 
C.    The operations of the organization must be supported from 3 sources as provided 
in this paragraph: 
 (1)  Fees collected pursuant to paragraphs A and B; 
 (2)  Annual assessments of not less than $100 assessed against the following 
entities licensed under Titles 24 and, 24-A and 32: nonprofit hospital and medical 
service organizations, health insurance carriers and health maintenance 
organizations on the basis of the total annual health care premium; and 3rd-party 
administrators, carriers that provide only administrative services for a plan 
sponsor and pharmacy benefits managers that process and pay claims on the basis 
of claims processed or paid for each plan sponsor.  The assessments are to be 
determined on an annual basis by the board.  Health care policies issued for 
specified disease, accident, injury, hospital indemnity, disability, long-term care 
or other limited benefit health insurance policies are not subject to assessment 
under this subparagraph.  For purposes of this subparagraph, policies issued for 
dental services are not considered to be limited benefit health insurance policies.  
The total dollar amount of assessments under this subparagraph must equal the 
assessments under subparagraph (3); and 
 (3)  Annual assessments of not less than $100 assessed by the organization 
against providers.  The assessments are to be determined on an annual basis by 
the board.  The total dollar amount of assessments under this subparagraph must 
equal the assessments under subparagraph (2). 
The aggregate level of annual assessments under subparagraphs (2) and (3) must be 
an amount sufficient to meet the organization's expenditures authorized in the state 
budget established under Title 5, chapter 149.  The annual assessment may not 
exceed $1,346,904 in fiscal year 2002-03.  In subsequent fiscal years, the annual 
assessment may increase above $1,346,904 by an amount not to exceed 5% per fiscal 
year.  The board may waive assessments otherwise due under subparagraphs (2) and 
(3) when a waiver is determined to be in the interests of the organization and the 
parties to be assessed. 
Sec. 4.  24-A MRSA §601, sub-§28, as enacted by PL 2009, c. 581, §3, is 
repealed. 
Sec. 5.  24-A MRSA §1913, as repealed and replaced by PL 2011, c. 443, §4, is 
repealed. 
Sec. 6.  24-A MRSA §4317, sub-§12 is enacted to read: 
12.  Maximum allowable cost.  This subsection governs the maximum allowable 
cost for a drug as determined by a pharmacy benefits manager. 
A.  As used in this subsection, unless the context otherwise indicates, the following 
terms have the following meanings. 
(1)  "Maximum allowable cost" means the maximum amount that a pharmacy 
benefits manager pays toward the cost of a drug. 
(2)  "Nationally available" means available to all pharmacies in this State for 
purchase, without limitation, from regional or national wholesalers and not 
obsolete or temporarily available. 
(3)  "Therapeutically equivalent drug substitute" means a drug identified as 
therapeutically or pharmaceutically equivalent to another drug by the United 
States Food and Drug Administration. 
B.  A pharmacy benefits manager may not set a maximum allowable cost for a 
prescription drug if that prescription drug does not have 3 or more nationally 
available therapeutically equivalent drug substitutes. 
C.  A pharmacy benefits manager shall remove a maximum allowable cost for a 
prescription drug or modify the maximum allowable cost as necessary for the cost of 
the prescription drug to remain consistent with changes in the national marketplace 
for prescription drugs.  A removal or modification made under this paragraph must be 
made in a timely fashion. 
D.  A pharmacy benefits manager shall disclose to a pharmacy for which the 
pharmacy benefits manager processes claims, makes payment of claims or procures 
drugs: 
(1)  At the beginning of each calendar year, the basis of the methodology and the 
sources used to establish the maximum allowable costs used by the pharmacy 
benefits manager.  A pharmacy benefits manager shall give prompt written 
notification to a pharmacy of any change made to a maximum allowable cost; 
and 
(2)  At least once every 7 business days, the maximum allowable costs used by 
the pharmacy benefits manager. 
E.  A pharmacy benefits manager shall establish a procedure by which a pharmacy 
may contest a maximum allowable cost.  A procedure established under this 
paragraph must require a pharmacy benefits manager to respond to a pharmacy that 
has contested a maximum allowable cost within 15 calendar days.  If the pharmacy 
benefits manager changes the maximum allowable cost, the change must: 
(1)  Become effective on the date on which the pharmacy initiated proceedings 
under this paragraph; and 
(2)  Apply to all pharmacies in the network of pharmacies served by the 
pharmacy benefits manager. 
F.  A pharmacy benefits manager shall disclose to a carrier with which the pharmacy 
benefits manager has entered into a contract: 
(1)  At the beginning of each calendar year, the basis of the methodology and the 
sources used to establish the maximum allowable costs used by the pharmacy 
benefits manager; 
(2)  As soon as practicable, any change made to a maximum allowable cost; 
(3)  The maximum allowable costs for prescription drugs dispensed at a retail 
community pharmacy not later than 21 business days after these costs are set; and 
(4)  Whether the pharmacy benefits manager used the same maximum allowable 
cost for billing the carrier and for reimbursing a pharmacy and, if the pharmacy 
benefits manager did not use the same maximum allowable cost, the difference 
between the amount billed and the amount reimbursed. 
Sec. 7.  32 MRSA §13800 is enacted to read: 
§13800.  Registration of pharmacy benefits managers 
A person may not act as a pharmacy benefits manager in this State without first 
paying the registration fee established by the board by rule. 
1.  Definitions.  As used in this section, the following terms have the following 
meanings. 
A.  "Administrator" has the same meaning as in Title 24-A, section 1901, subsection 
1. 
B.  "Health maintenance organization" has the same meaning as in Title 24-A, section 
4202-A, subsection 10. 
C.  "Pharmacy benefits manager" means a person or entity that contracts with a plan 
sponsor, health care service plan, health maintenance organization or insurer to 
manage or administer a contract, agreement or arrangement between a carrier or 
administrator and a pharmacy, as defined in Title 32, section 13702-A, subsection 24, 
in which the pharmacy agrees to provide services to a health plan enrollee whose plan 
benefits include incentives for the enrollee to use the services of that pharmacy. 
D.  "Plan sponsor" has the same meaning as in Title 24-A, section 1901, subsection 8. 
2.  Rules.  The board may adopt routine technical rules pursuant to Title 5, chapter 
375, subchapter 2-A to administer and enforce the registration requirements of this 
section.  Pharmacy benefits manager registration fees established by the board may not 
exceed $100 for an original registration or an annual renewal registration. 
3.  Enforcement.  The board may enforce this section. 
Sec. 8.  Maine Board of Pharmacy to adopt rules.  The Department of 
Professional and Financial Regulation, Maine Board of Pharmacy shall adopt routine 
technical rules pursuant to the Maine Revised Statutes, Title 5, chapter 375, subchapter 
2-A to administer and enforce the requirements regarding the registration of pharmacy 
benefits managers in Title 32, section 13800 no later than January 1, 2015. 
Sec. 9.  Effective date.  Those sections of this Act that enact the Maine Revised 
Statutes, Title 32, section 13800, amend Title 22, section 1711-E, subsection 1, paragraph 
G, Title 22, section 8702, subsection 8-B and Title 22, section 8706 and repeal Title 
24-A, section 601, subsection 28 and Title 24-A, section 1913 take effect January 1, 
2015. 
SUMMARY 
This bill sets limits on the use of maximum allowable cost pricing by pharmacy 
benefits managers and requires pharmacy benefits managers to make disclosures 
regarding that pricing.  It also transfers oversight and enforcement of the laws governing 
the registration of pharmacy benefits managers from the Superintendent of Insurance to 
the Department of Professional and Financial Regulation, Maine Board of Pharmacy.