Md. Code Regs. 17.04.15.04

Current through Register Vol. 51, No. 24, December 2, 2024

Section 17.04.15.04 - Purchasing Pool Member Responsibilities

A. Each purchasing pool member shall:

(1) Permit the Department to have access to enrollment information (limited to participant names, Social Security numbers, enrollment tier, and plan design) for purposes of Maryland Rx Program administration, such as general reporting, auditing, and verifying eligibility of the entity as a purchasing pool member;

(2) Pay all the costs and fees, including but not limited to claims costs, administrative fees, and dispensing fees, associated with its own prescription benefits plan administered as part of the Maryland Rx Program;

(3) Provide enrollment and eligibility data to the contractor as necessary to administer the pharmacy or prescription benefits plan administered as part of the Maryland Rx Program;

(4) Negotiate the administrative services to be provided in administering the purchasing pool member's prescription drug plan and the administrative fees paid by the purchasing pool member for those services, the negotiations to be with the Department's contractor, agent, or representative identified by the Department for management and administration of the Maryland Rx Program;

(5) Commit to participating in the Maryland Rx Program for a full 12 month plan year period at a time; and manager and to provide aggregate enrollment information to the State for administration of the Maryland Rx Program; and

(6) Acknowledge that the purchasing pool member remains the sponsor of the entity's own prescription benefits plan for its employees and is responsible for the administration, legality, and operation of that plan.

B. Plan Design.

(a) Have the same formulary and preferred drug list as the State prescription drug benefits plan operated as part of the Program;

(b) Use the same pharmacy network as the State prescription drug benefits plan operated as part of the Program;

(c) Have the same number and structure for copayments as the State prescription benefits plan operated as part of the Program;

(d) Have at least a $10 differential between brand formulary (for example, preferred) and brand nonformulary (for example, nonpreferred) drugs covered through the plan; and

(e) Coverage for up to a 45-day supply for a single copayment.

(1) A purchasing pool member may choose a copayment structure for the plan design of the pharmacy or prescription benefits plan that it shall sponsor and administer as part of the Maryland Rx Program and is not limited by the copayment structure set by the State for the State's prescription benefits plan operated as part of the Program.

(2) Except as otherwise provided in this chapter, each purchasing pool member may determine the design of, and who is eligible for, coverage in its own prescription benefits plan.

C. A purchasing pool member shall set the fully insured equivalent premiums (including employee and employer portion as applicable) for its own self-funded plan and is not limited by premiums and employer contributions set by the State for the State's plan operated as part of the Program.

D. A purchasing pool member may set the start and end date of its 12 month plan year. Implementation services and schedules may be negotiated between the purchasing pool member and the contractor described in Regulation .06 of this chapter.

Md. Code Regs. 17.04.15.04

Regulation .04 amended effective 42:21 Md. R. 1303, eff.10/26/2015