​HB 601 – PBM: DEFINITION OF A PURCHASER AND ERISA – BY DELEGATE KIPKE

STATUS UPDATE: Signed by the Governor

Law Effective January 1, 2022

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FOR the purpose of altering the definition of “purchaser” for the purposes of certain provisions of State insurance law governing pharmacy benefits managers to repeal the exclusion of certain persons that provide prescription drug coverage or benefits through plans subject to ERISA; repealing a certain definition, and generally relating to pharmacy benefits managers and plans subject to ERISA. 

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Importance:

By amending the Insurance Article, this bill streamlines the definition of "pharmacy benefits manager" in relation to their purpose in the healthcare system and implements elements of the Rutledge v PCMA SCOTUS decision by allowing the state to regulate ERISA plan PBM practices. It also places restrictions and guidelines on pharmacy audits to prevent predatory tactics, and broadens the scope of care pharmacies may provide to their patients.

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​HB 602 – EMERGENCY BILL MMCD/PBM REIMBURSEMENT REUIREMENT - BY DELEGATE KIPKE

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*   A  PBM must reimburse the pharmacy an amount that is at least equal to the National Average Drug Acquisition Cost (NADAC), plus the fee for service – professional dispensing fee determined by the Marylan Department of Health or the Maryland Medical Assistance Program in accordance with the most recent in-state cost of dispensing survey

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​HB 603 – PHARMACY BENEFITS MANAGERS – EXPLANATION OF BENEFITS - BY DELEGATE KIPKE

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*   On a quarterly basis a PBM shall provide an explanation of benefits statement, on a form approved by the commissioner, to each beneficiary for whom the PBM processed or paid a claim for prescription drugs during the immediately preceding 3-month period.

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The EOB will contain the following:

• a copayment or other cost-sharing amount paid by the beneficiary

• the amount of the payment, reimbursement, or other disbursement made to the dispensing pharmacy by the PBM 

• the amount billed by the PBM to the purchaser

• other information that the commissioner requires by regulation to ensure that the EOB statement provides the beneficiary with accurate and clear information regarding the processing and reimbursement of claims by the PBM

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HB 607 – STATE HEALTH & WELFARE BENEFITS PROGRAM: REQUIREMENTS FOR SELECTION OF A PHARMACY BENEFITS MANAGER – BY DELEGATE KIPKE

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AMENDMENT TO THE 2020 LEGISLATIVE SESSION REVERSE AUCTION BILL

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Terms of a participant bidding agreement: 

• all bidders must accept as a prerequisite for participation in the reverse auction shall include a requirement that a bidder, if selected as a PBM for the Maryland Prescription Drug Program, pay a fee-for-service professional dispensing fee to a pharmacy which is based on an in-state cost to dispense market survey

• the department shall require that the fee-for-service professional dispensing fee required will be stated by the bidder in the bid submitted in the reverse auction

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HB 709/SB 614 – PBM - DRUG REIMBURSEMENT - REPORTING REQUIREMENTS – By DELEGATE KREBS / SENATOR JUSTIN READY

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This provision of the insurance article will apply to PBMs that contract with Managed Care Organizations (MCOs) in the same manner as they apply to PBMs that contract with carriers.

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Beginning January 1, 2022, and every 3 months thereafter, each PBM shall file with the Commissioner a report of all drugs appearing on the National Drug Acquisition Cost (NADAC) List that were reimbursed by the PBM at an amount below the NADAC cost plus the fee-for-service professional dispensing fee determined by the MD Dept. of Health for the MD Medical Assistance Program in accordance with the most recent in-state cost-of-dispensing survey.

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For each drug listed on the report the following must be included:

• the month the drug was dispensed

• the quantity of the drug that was dispensed

• the amount the pharmacy was reimbursed per unit or dosage

• whether the dispensing pharmacy was an affiliate of the PBM

• whether the drug was reimbursed in accordance with a state or local government health plan

• the NADAC cost on the day the drug was dispensed

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This information will be made available to the public by the Commissioner. This subsection may not be construed to preempt or conflict with any federal law or regulation (ERISA)

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​HB 819/SB 615 – PBMs - PROHIBITED ACTIONS. BY DELEGATE KREBS / SENATOR JUSTIN READY​

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The bill adds to actions that may not be taken by a Pharmacy Benefit Manager (PBM) against a pharmacy. Under the bill, a PBM may not:

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• diminish reimbursement to a pharmacy for a prescription based on patient outcomes; 

• engage in the practice of “spread pricing”, which is where the PBM charges a prescription plan one price for a drug, and then pays the pharmacy a lesser amount, the PBM then pocketing the difference; 

• deny any pharmacy the right to participate in a prescription plan, as long as the pharmacy agrees to meet the terms and conditions of the plan; 

• set different fees for a copay, based on whether the pharmacy is affiliated with an independent or a chain pharmacy; 

• require that a beneficiary of a plan use a mail-order pharmacy to fill a prescription.
   

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