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§ 15-852. Prorated daily copayment or coinsurance amount for partial supply of prescription dru...

West's Annotated Code of MarylandInsuranceEffective: January 1, 2019

West's Annotated Code of Maryland
Insurance (Refs & Annos)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits (Refs & Annos)
Effective: January 1, 2019
MD Code, Insurance, § 15-852
§ 15-852. Prorated daily copayment or coinsurance amount for partial supply of prescription drug
Definitions
(a)(1) In this section the following words have the meanings indicated.
(2) “In-network pharmacy” means a pharmacy that is among the participating providers with which an entity subject to this section contracts to provide health care services to members.
(3) “Member” means an individual entitled to health care benefits for prescription drugs or devices under a policy issued or delivered in the State by an entity subject to this section.
Scope of section
(b)(1) This section applies to:
(i) insurers and nonprofit health service plans that provide coverage for prescription drugs and devices under health insurance policies or contracts that are issued or delivered in the State; and
(ii) health maintenance organizations that provide coverage for prescription drugs and devices under contracts that are issued or delivered in the State.
(2) An insurer, a nonprofit health service plan, or a health maintenance organization that provides coverage for prescription drugs and devices through a pharmacy benefits manager is subject to the requirements of this section.
In general
(c) An entity subject to this section shall allow and apply a prorated daily copayment or coinsurance amount for a partial supply of a prescription drug dispensed by an in-network pharmacy if:
(1) the prescriber or the pharmacist determines dispensing a partial supply of a prescription drug to be in the best interest of the member;
(2) the prescription drug is anticipated to be required for more than 3 months;
(3) the member requests or agrees to a partial supply for the purpose of synchronizing the dispensing of the member's prescription drugs;
(4) the prescription drug is not a Schedule II controlled dangerous substance; and
(5) the supply and dispensing of the prescription drug meets all prior authorization and utilization management requirements specific to the prescription drug at the time of the synchronized dispensing.
Denial of payment of benefits prohibited
(d) Subject to subsection (c) of this section, an entity subject to this section:
(1) may not deny payment of benefits to an in-network pharmacy for a covered prescription drug solely on the basis that only a partial supply of the prescription drug was dispensed; and
(2) shall allow an in-network pharmacy to override any denial codes indicating that a prescription is being refilled too soon.
Prorated dispensing fees prohibited
(e) Subject to subsection (c) of this section, an entity subject to this section:
(1) may not use a payment structure that incorporates prorated dispensing fees for dispensing a partial supply of a prescription drug; and
(2) shall pay an in-network pharmacy a full dispensing fee for dispensing a partial supply of a prescription drug under this section, regardless of:
(i) any prorated copayment or coinsurance amount charged to a member; or
(ii) any fee paid to the pharmacy for synchronizing a member's prescriptions.

Credits

Added by Acts 2017, c. 766, § 1, eff. Jan. 1, 2019; Acts 2017, c. 767, § 1, eff. Jan. 1, 2019.
MD Code, Insurance, § 15-852, MD INSURANCE § 15-852
Current through legislation effective through April 9, 2023, from the 2024 Regular Session of the General Assembly. Some statute sections may be more current, see credits for details.
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