EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
*hb1008*
HOUSE BILL 1008
J5 2lr1853
By: Delegate Kipke
Introduced and read first time: February 10, 2022
Assigned to: Health and Government Operations
A BILL ENTITLED
AN ACT concerning 1
Pharmacy Benefits Managers and Purchasers – Beneficiary Choice of Pharmacy 2
FOR the purpose of prohibiting a pharmacy benefits manager or purchaser from prohibiting 3
a beneficiary from selecting a pharmacy or pharmacist of the beneficiary’s choosing, 4
denying a pharmacy or pharmacist the right to participate in a network, imposing 5
certain monetary advantages or penalties on a beneficiary, or requiring the use of a 6
mail–order pharmacy, under certain circumstances; requiring a pharmacy benefits 7
manager or purchaser that restricts participation in a geographical network to notify 8
all pharmacies in the geographic area of the opportunity to participate in the 9
network; authorizing a beneficiary, pharmacy, or pharmacist to maintain a cause of 10
action for violations of the requirements of this Act; and generally relating to 11
pharmacy benefits managers and purchasers. 12
BY repealing and reenacting, without amendments, 13
Article – Insurance 14
Section 15–1601(a), (c), (l), (m), (n), (o), (p), (q), and (s) 15
Annotated Code of Maryland 16
(2017 Replacement Volume and 2021 Supplement) 17
BY repealing 18
Article – Insurance 19
Section 15–1611.1 20
Annotated Code of Maryland 21
(2017 Replacement Volume and 2021 Supplement) 22
BY adding to 23
Article – Insurance 24
Section 15–1611.1 25
Annotated Code of Maryland 26
(2017 Replacement Volume and 2021 Supplement) 27
2 HOUSE BILL 1008
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 1
That the Laws of Maryland read as follows: 2
Article – Insurance 3
15–1601. 4
(a) In this subtitle the following words have the meanings indicated. 5
(c) “Beneficiary” means an individual who receives prescription drug coverage or 6
benefits from a purchaser. 7
(l) “Participating pharmacy contract” means a contract filed with the 8
Commissioner in accordance with § 15–1628(b) of this subtitle. 9
(m) “Pharmacist” has the meaning stated in § 12–101 of the Health Occupations 10
Article. 11
(n) “Pharmacy” has the meaning stated in § 12–101 of the Health Occupations 12
Article. 13
(o) “Pharmacy and therapeutics committee” means a committee established by a 14
pharmacy benefits manager to: 15
(1) objectively appraise and evaluate prescription drugs; and 16
(2) make recommendations to a purchaser regarding the selection of drugs 17
for the purchaser’s formulary. 18
(p) (1) “Pharmacy benefits management services” means: 19
(i) the procurement of prescription drugs at a negotiated rate for 20
dispensation within the State to beneficiaries; 21
(ii) the administration or management of prescription drug coverage 22
provided by a purchaser for beneficiaries; and 23
(iii) any of the following services provided with regard to the 24
administration of prescription drug coverage: 25
1. mail service pharmacy; 26
2. claims processing, retail network management, and 27
payment of claims to pharmacies for prescription drugs dispensed to beneficiaries; 28
3. clinical formulary development and management services; 29
HOUSE BILL 1008 3
4. rebate contracting and administration; 1
5. patient compliance, therapeutic intervention, and generic 2
substitution programs; or 3
6. disease management programs. 4
(2) “Pharmacy benefits management services” does not include any service 5
provided by a nonprofit health maintenance organization that operates as a group model, 6
provided that the service: 7
(i) is provided solely to a member of the nonprofit health 8
maintenance organization; and 9
(ii) is furnished through the internal pharmacy operations of the 10
nonprofit health maintenance organization. 11
(q) “Pharmacy benefits manager” means a person that performs pharmacy 12
benefits management services. 13
(s) “Purchaser” means a person that offers a plan or program in the State, 14
including the State Employee and Retiree Health and Welfare Benefits Program, that: 15
(1) provides prescription drug coverage or benefits in the State; and 16
(2) enters into an agreement with a pharmacy benefits manager for 17
the provision of pharmacy benefits management services. 18
[15–1611.1. 19
(a) This section applies only to a pharmacy benefits manager that provides 20
pharmacy benefits management services on behalf of a carrier. 21
(b) Except as provided in subsection (c) of this section, a pharmacy benefits 22
manager may not require that a beneficiary use a specific pharmacy or entity to fill a 23
prescription if: 24
(1) the pharmacy benefits manager or a corporate affiliate of the pharmacy 25
benefits manager has an ownership interest in the pharmacy or entity; or 26
(2) the pharmacy or entity has an ownership interest in the pharmacy 27
benefits manager or a corporate affiliate of the pharmacy benefits manager. 28
(c) A pharmacy benefits manager may require a beneficiary to use a specific 29
pharmacy or entity for a specialty drug as defined in § 15–847 of this title.] 30
15–1611.1. 31 4 HOUSE BILL 1008
(A) IN THIS SECTION, “CONTRACTED PROVIDER ” MEANS A PHARMACY OR 1
PHARMACIST THAT PARTICIPATES IN THE NETWORK OF A PHA RMACY BENEFITS 2
MANAGER OR PURCHASER THROUGH A PARTICIPATING PHARMA CY CONTRACT WITH 3
THE PHARMACY BENEFITS MA NAGER OR PURCHASER . 4
(B) UNLESS THE ENTITY CON TRACTS WITH AN OUTSIDE PHAR MACY OR 5
GROUP OF PHARMACIES TO PROVIDE PRESCRIPT ION DRUGS AND SERVIC ES, THIS 6
SECTION DOES NOT APPLY TO AN ENTITY THAT: 7
(1) HAS ITS OWN FACILITY ; 8
(2) EMPLOYS OR CONTRACTS WITH PHYSICIANS , PHARMACISTS , 9
NURSES, AND OTHER HEALTH CAR E PERSONNEL; AND 10
(3) DISPENSES PRESCRIPTI ON DRUGS FROM ITS OW N PHARMACY TO 11
ITS EMPLOYEES AND DE PENDENTS ENROLLED IN ITS HEALTH BENEFIT P LAN. 12
(C) A PHARMACY BENEFITS MA NAGER OR PURCHASER MAY NOT: 13
(1) PROHIBIT A BENEFICIARY FROM S ELECTING, OR LIMITING A 14
BENEFICIARY’S ABILITY TO SELECT , A PHARMACY OR PHARMA CIST OF THE 15
BENEFICIARY’S CHOICE IF THE PHARMACY OR PHARMACI ST HAS AGREED TO 16
PARTICIPATE AS A CONTRACTED PROV IDER FOR THE PHARMACY BENEFITS 17
MANAGER OR PURCHASER ; 18
(2) DENY A PHARMACY OR PH ARMACIST THE RIGHT T O PARTICIPATE 19
AS A CONTRACT PROVID ER UNDER A PARTICIPATING PHAR MACY CONTRACT IF THE 20
PHARMACY OR PHARMACI ST AGREES TO THE TERMS AND REQUIREMENTS FOR 21
PARTICIPATING IN THE PHARMACY BENEFITS MA NAGER’S OR PURCHASER ’S 22
NETWORK FOR THE GEOGRAPHICAL AREA, INCLUDING REQUIREMENTS FOR: 23
(I) PROVIDING PHARMACY SERVICES , INCLUDING DISPENSING 24
PRESCRIPTION DRUGS ; AND 25
(II) REIMBURSEMENT ; 26
(3) IMPOSE ON A BENEFICIA RY ANY COPAYMENT , FEE, OR CONDITION 27
THAT IS NOT EQUALLY IMPOSED ON ALL BENEF ICIARIES IN THE SAME BENEFIT 28
CATEGORY, CLASS, OR COPAYMENT LEVEL IF THE BENEFICIARY I S RECEIVING 29
PHARMAC Y SERVICES FROM A CONT RACT PROVIDER ; 30
HOUSE BILL 1008 5
(4) IMPOSE A MON ETARY ADVANTAGE OR P ENALTY THAT WOULD 1
AFFECT A BENEFICIARY ’S CHOICE OF CONTRACTED PROVID ERS, INCLUDING: 2
(I) CHARGING DIFFERENT COPAYMENT S FOR DIFFERENT 3
CONTRACTED PROVIDERS ; 4
(II) REDUCING REIMBURSEMENT FOR SE RVICES; OR 5
(III) PROMOTING ONE CONTRACT PROVIDE R OVER ANOTHER 6
CONTRACT PROVIDER ; 7
(5) REDUCE ALLOWABLE REIM BURSEMENT FOR PHARMA CY 8
SERVICES TO A BENEFI CIARY BECAUSE THE BE NEFICIARY SELECTS ONE CONTRACT 9
PROVIDER OVER ANOTHE R; 10
(6) REQUIRE A BENEFICIARY , AS A CONDITION OF PA YMENT OR 11
REIMBURSEMENT , TO PURCHASE PHARMACY SERVICES, INCLUDING PRESCRIPTI ON 12
DRUGS, EXCLUSIVELY THROUGH A MAIL–ORDER PHARMACY ; OR 13
(7) IMPOSE ON A BENEFICIA RY A COPAYMENT , AN AMOUNT OF 14
REIMBURSEMENT , A LIMITATION ON THE NUMBER OF DAYS OF A DRUG SUPPLY FOR 15
WHICH REIMBURSEMENT WIL L BE ALLOWED , OR ANY OTHER PAYMENT OR 16
CONDITION RELATING T O THE PURCHASE OF A PHARMACY SERVICE FRO M A 17
PHARMACY THAT IS MORE COSTLY OR MORE RESTRICTIVE TO A BENEFICIARY THA N 18
WOULD BE IMPOSED ON THE BENEFICIARY IF THE SAME PHARMACY SERVICE WERE 19
PURCHASED FROM A MAI L–ORDER PHARMACY OR AN Y OTHER PHARMACY THA T IS 20
WILLING TO PROVIDE T HE SAME SERVICES OR PRODUCTS FOR THE SAM E COST AND 21
COPAYMENT AS ANY MAI L–ORDER SERVICE . 22
(D) (1) IF A PHARMACY BENEFITS MA NAGER OR A PURCHASER 23
RESTRICTS PHARMACY P ARTICIPATION OF CONTRACTED PROVIDER S IN A 24
GEOGRAPHICAL COVERAG E AREA, THE PHARMACY BENEFITS MA NAGER OR 25
PURCHASER SHALL NOTIFY , IN WRITING, ALL PHARMACIES AND PHARMACISTS 26
WITHIN THE GEOGRAPHI CAL COVERAGE AREA OF THE PHARMACY BENEFITS 27
MANAGER’S OR PURCHASER ’S NETWORK , AND OFFER TO THE PHA RMACIES AND 28
PHARMACISTS THE OPPORTUNITY TO P ARTICIPATE IN THE NETWORK AT LEAST 60 29
DAYS BEFORE THE EFFECTIVE DATE O F THE RESTRICTIONS . 30
(2) ALL PHARMACISTS OR PHARMACIES IN THE GE OGRAPHICAL 31
COVERAGE ARE A OF THE NETWORK SHALL BE ELIGIBLE TO PARTICIPATE UNDER 32
IDENTICAL REIMBURSEM ENT TERMS FOR PROVID ING PHARMACY SERVICE S, 33
INCLUDING PRESCRIPTI ON DRUGS. 34
6 HOUSE BILL 1008
(3) THE PHARMACY BENEFITS MA NAGER OR PURCHASER SHALL, 1
THROUGH REASONABLE M EANS, ON A TIMELY BASIS AN D AT REGULAR INTERVALS , 2
INFORM ITS BENEFICIARIES OF THE NAMES AND LOCATIONS OF PHARMACIES AND 3
PHARMACISTS THAT ARE PARTICIPATI NG IN THE NETWORK AS CONTRACTED 4
PROVIDERS. 5
(4) CONTRACTED PROVIDERS MAY ANNOUNCE THEIR 6
PARTICIPATION TO THE IR CUSTOMERS THROUGH A MEANS ACCEPTABLE T O THE 7
CONTRACTED PROVIDER AND PHARMACY BENEFIT S MANAGER OR PURCHAS ER. 8
(E) THE COMMISSIONER MAY DISAPPROVE A PARTICIPATING CONTRACT 9
THAT DOES NOT COMPLY WITH THIS SECTION. 10
(F) A BENEFICIARY, PHARMACY, OR PHARMACIST INJURED BY A VIOLATI ON 11
OF THIS SECTION MAY MAINTAIN A CAUSE OF ACTION TO ENJOIN THE CONTINUANCE 12
OF THE VIOLATION. 13
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect 14
October 1, 2022. 15