Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.46 - Pharmacy Benefits Managers-Maximum Allowable Cost › Section 31.10.46.02 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Appeal decision" means a written or electronic notice issued by a PBM in response to an appeal filed by a contracted pharmacy of the maximum allowable cost used to adjudicate a claim.
(2) "Beneficiary" means an individual who receives prescription drug coverage or benefits from a purchaser.
(3) "Carrier" has the meaning stated in Insurance Article §
										15-1601, Annotated Code of Maryland.
(4) "Compensation program" has the meaning stated in Insurance Article, §
										15-1601, Annotated Code of Maryland.
(5) "Contracted pharmacy" has the meaning stated in Insurance Article, §
										15-1601, Annotated Code of Maryland.
(6) "MAC complaint" means a communication by a contracted pharmacy that disputes the appeal decision, and is submitted on a MAC complaint form to the Commissioner, after the pharmacy benefits manager's internal appeal process has been exhausted as required by Insurance Article, §
										15-1628.1(f), Annotated Code of Maryland.
(7) "MAC complaint form" means the form adopted by the Commissioner under Regulation .05 of this chapter.
(8) "MAC list" means a list of multisource generic drugs, medical products, and devices for which a MAC has been established by a pharmacy benefits manager or a purchaser.
(9) "Maximum allowable cost" or "MAC" has the meaning stated in Insurance Article, §
										15-1628.1, Annotated Code of Maryland.
(10) "Multisource generic drug" means a generic drug as defined in Health-General Article, § 21-2C-01(f), Annotated Code of Maryland, for which there is at least one other drug and does not include a brand name drug as that term is defined in Health Occupations, § 12-504, Annotated Code of Maryland.
(11) "Participating pharmacy contract" means a contract filed with the Commissioner that is:
(a) Between a pharmacy and a:
(i) Pharmacy benefits manager;
(ii) Pharmacy services administrative organization; or
(iii) Group purchasing organization;
(b) Filed as required by the Commissioner;
(c) Not disapproved by the Commissioner; and
(d) In compliance with the requirements stated in this chapter.
(12) "Pharmacist" has the meaning stated in Health Occupations Article, §
										12-101, Annotated Code of Maryland.
(13) "Pharmacy" has the meaning stated in Health Occupations Article, §
										12-101, Annotated Code of Maryland.
(14) "Pharmacy benefits management services" has the meaning stated in Insurance Article, §
										15-1601, Annotated Code of Maryland.
(15) "Pharmacy benefits manager" or "PBM" has the meaning stated in Insurance Article, §
										15-1601, Annotated Code of Maryland.
(16) "Pharmacy services administration organization" or "PSAO" means an entity that provides a contracted pharmacy with contracting administrative services relating to prescription drug benefits.
(17) "Pricing information" means anything used in the mathematical calculation to determine the payment to a contracted pharmacy.
(18) "Purchaser" has the meaning stated in Insurance Article, §
										15-1601, Annotated Code of Maryland.
(19) "Source " means the publisher or publishers stated in the participating pharmacy contract, used by the PBM, in any manner, to establish the basis of the PBM's MAC reimbursement amount to a contracted pharmacy, under a participating pharmacy contract compensation program.
(20) "Working day" means any day that the Maryland Insurance Administration is open for business.