Md. Code Regs. 31.10.46.05

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

Section 31.10.46.05 - MAC Complaint Process

A. Prior to filing a MAC complaint with the Commissioner, a contracted pharmacy or its designee shall exhaust the internal appeal process established in the participating pharmacy contract and used by the PBM to appeal, investigate, and resolve a dispute regarding the MAC claim amount.

B. A contracted pharmacy or its designee may file a MAC complaint with the Commissioner to dispute a PBM's appeal decision for the following reasons:

(1) The PBM's MAC pricing did not meet the requirements of Insurance Article, Title 15, Subtitle 16, Annotated Code of Maryland, related to MAC pricing; or

(2) The PBM's MAC pricing did not meet the applicable terms of the applicable participating pharmacy contract.

C. A MAC complaint is properly completed and may be filed if a contracted pharmacy or designee:

(1) Completes all applicable portions of the Commissioner's MAC complaint form;

(2) Provides a copy of the relevant contract or the provisions that are related to the MAC appeal, including but not limited to:

(a) MAC;

(b) MAC pricing;

(c) Sources;

(d) Pricing information; and

(e) The compensation program of the applicable participating pharmacy contract; and

(3) Provides a copy of the appeal decision.

D. A MAC complaint may not include more than ten appeal decisions using a single MAC complaint form.

E. Notification of the MAC Complaint to the PBM.

(1) Upon receipt of a completed MAC complaint form, the Commissioner shall provide a copy of the submitted MAC complaint form to the PBM.

(2) Within 5 working days of receiving the Commissioner's notice, the PBM shall provide the Commissioner:

(a) A complete, unredacted copy of the applicable portion of the participating pharmacy contract relating to the compensation program and the complaint filed with the Commissioner, including any other contract under which the pricing information is determined;

(b) A copy of the applicable source and pricing information used to calculate the MAC;

(c) The MAC calculated on a per unit basis based on the same generic product identifier or national drug code number;

(d) A mathematical calculation that demonstrates how the reimbursement amount was determined;

(e) All information required to complete the response portion of the MAC complaint form; and

(f) Any other information the Commissioner may require for the purposes of determining a PBM's compliance with:

(i) Insurance Article, Annotated Code of Maryland;

(ii) This chapter;

(iii) The compensation program; or

(iv) The applicable terms of the applicable participating pharmacy contract.

Md. Code Regs. 31.10.46.05

Regulation .05 adopted effective 47:6 Md. R. 343, eff. 3/23/2020