An Act Regarding Maximum Allowable Cost Pricing Lists Used by Pharmacy Benefit Managers
Maine Legislature, Session 127, LD 1150
Committee Amendment CA_B_H556 (House)
Amends: 24-A MRSA §4317

COMMITTEE AMENDMENT ,J3,, to H.P. 788, L.D. 1150, Bill, "An Act 
Regarding Maximum Allowable Cost Pricing Lists Used by Pharmacy Benefit Managers" 
Amend the bill by striking out everything after the enacting clause and before the 
summary and inserting the following: 
'Sec. 1. 24-A MRSA §4317, sub-§12 is enacted to read: 
12. Maximum allowable cost. This subsection governs the maximum allowable 
cost for a prescription drug as determined by a pharmacy benefits manager. 
A. 
As used in this subsection, "maximum allowable cost" means the maximum 
amount that a pharrilacy benefits manager pays toward the cost of a prescription drug. 
B. 
A pharmacy benefits manager may set a maximum allowable cost for a 
prescription drug, or allow a prescription drug to continue on a maximum allo_wable 
cost list, only if that prescription drug: 
(1) Is rated as "A" or "B" in the most recent version of the United States Food 
and Drug Administration's "Approved Drug Products with Therapeutic 
Equivalence Evaluations," also known as "the Orange Book," or an equivalent 
rating from a successor publication, or is rated as "NR" or "NA" or a similar 
rating by a nationally recognized pricing reference; and 
(2) Is not obsolete and is generally available for purchase in this State from a 
national or regional wholesale distributor by pharmacies having a contract with 
the pharmacy benefits manager. 
C. 
A pharmacy benefits manager shall establish a process for removing a 
prescription drug from a maximum allowable cost list or modifying a maximum 
allowable cost for a prescription drug in a timely manner to remain consistent with 
changes to such costs and the availability of the drug in the national marketplace. 
D. 
With regard to a pharmacy with which the pharmacy benefits manager has 
entered into a contract, a pharmacy benefits manager shall: 
Page I - 127LR0476(05)-l 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT .Ct>,, to H.P. 788, L.D. 1150 
(l} Upon request, disclose the sources used to establish the maximum allowable 
costs used by the pharmacy benefits manager; 
(2) Provide a process for a pharmacy to readily obtain the maximum allowable 
reimbursement available to that pharmacy under a maximum allowable cost list; 
and 
(3) At least once every 7 business days, review and update maximum allowable 
cost list information to reflect any modification of the maximum allowable 
reimbursement available to a pharmacy under a maximum allowable cost list 
used by the pharmacy benefits manager. 
E. A pharmacy benefits manager shall provide a reasonable administrative appeal 
procedure, including a right to appeal that is limited to 14 days following the initial 
claim, to allow pharmacies with which the pharmacy benefits manager has a contract 
to challenge maximum allowable costs for a specified drug. 
F. 
The pharmacy benefits manager shall respond to, investigate and resolve an 
appeal under paragraph E within 14 days after the receipt of the appeal. The 
pharmacy benefits manager shall respond to an appeal as follows: 
( l} If the appeal is upheld, the pharmacy benefits manager shall make the 
appropriate adjustment in the maximum allowable cost and permit the 
challenging pharmacy or pharmacist to reverse and rebill the claim in question; or 
(2) If the appeal is denied, the pharmacy benefits manager shall provide the 
challenging pharmacy or pharmacist the national drug code from national or 
regional wholesalers of a comparable prescription drug that may be purchased at 
or below the maximum allowable cost. 
G. The requirements of this subsection apply to contracts between a pharmacy and a 
pharmacy benefits manager executed or renewed on or after September 1, 2016.' 
SUMMARY 
This amendment replaces the bill. The amendment establishes certain requirements 
relating to maximum allowable cost pricing lists used by pharmacy benefits managers. 
The amendment provides that a pharmacy benefits manager may set a maximum 
allowable cost for a prescription drug only if that drug is rated as "A" or "B" in the most 
recent version of the United States Food and Drug Administration's "Approved Drug 
Products with Therapeutic Equivalence Evaluations," also known as "the Orange Book," 
or an equivalent rating from a successor publication, or is rated as "NR" or "NA" or a 
similar rating by a nationally recognized pricing reference and the drug is not obsolete 
and is generally available for purchase in this State. 
The amendment requires a pharmacy benefits manager to remove or modify in a 
7 
timely manner a maximum allowable cost for a prescription drug as necessary for the cost 
of the prescription drug to remain consistent with changes to such costs and availability 
9 
of the drug in the national marketplace for prescription drugs. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT ,;B" to H.P. 788, L.D. 1150 
The amendment requires a pharmacy benefits manager to provide the following to a 
pharmacy with which the pharmacy benefits manager has a contract: 
1. Disclose the sources used to establish the maximum allowable costs used by the 
pharmacy benefits manager upon request; 
2. 
Provide a process for a pharmacy to readily obtain the maximum allowable 
reimbursement available to that pharmacy under a maximum allowable cost list; and 
3. At least once every 7 business days, review and update maximum allowable cost 
list information to reflect any modification of the maximum allowable reimbursement 
available to a pharmacy under a maximum allowable cost list used by the pharmacy 
benefits manager. 
The amendment establishes an appeal process to allow a pharmacy to challenge a 
drug's maximum allowable cost under certain conditions. 
The amendment specifies that the provisions apply to contracts between a pharmacy 
benefits manager and a pharmacy beginning September 1, 2016. 
FISCAL NOTE REQUIRED 
(See attached) 
COMMITTEE AMENDMENT 
• 
Approved: 03/04/16 
;t;,/ac.. 
LD 1150 
LR 476(05) 
An Act Regarding Maximum Allowable Cost Pricing Lists Used by Pharmacy Benefit Managers 
Fiscal Note for Bill as Amended by Committee Amendment i5 l H--ss&) 
Committee: Insurance and Financial Services 
Net Cost (Savings) 
General Fund 
Highway Fund 
Appropriations/ Allocations 
General Fund 
Highway Fund 
Fiscal Detail and Notes 
Fiscal Note Required: Yes 
Fiscal Note 
FY 2015-16 
$0 
$0 
$0 
$0 
FY 2016-17 
$0 
$0 
$0 
$0 
Projections 
FY 2017-18 
$97,155 
$3,244 
$97,155 
$3,244 
Projections 
FY 2018-19 
$97,155 
$3,244 
$97,155 
$3,244 
This bill will increase costs to the State Employee Health Plan due to the change in the maximum allowable costs list 
rules for pharmacy benefits managers for contracts beginning on or after September 1, 2016. The bill would not have 
any impact on the current biennial budget since the State's Contract with a pharmacy benefits manager ends on June 
30, 2017. Moving forward it is estimated that there will be an annual cost of$97,155 to the General Fund and $3,244 
to the Highway Fund for contributions to the costs of the State Employee Health Plan. 
LR0476(05) - Fiscal Note - Page 1 of 1