EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
[Brackets] indicate matter deleted from existing law.
*sb0975*
SENATE BILL 975
J5 5lr2643
CF 5lr2645
By: Senator Lam
Introduced and read first time: January 28, 2025
Assigned to: Finance
A BILL ENTITLED
AN ACT concerning 1
Health Insurance – Coverage for Specialty Drugs 2
FOR the purpose of prohibiting certain insurers, nonprofit health service plans, and health 3
maintenance organizations from excluding coverage for certain specialty drugs that 4
are administered or dispensed by a provider that meets certain criteria; requiring 5
the reimbursement rate for certain specialty drugs to meet certain criteria; and 6
generally relating to health insurance coverage for specialty drugs. 7
BY repealing and reenacting, without amendments, 8
Article – Insurance 9
Section 15–847(a)(1) and (5) 10
Annotated Code of Maryland 11
(2017 Replacement Volume and 2024 Supplement) 12
BY repealing and reenacting, with amendments, 13
Article – Insurance 14
Section 15–847(d), 15–1611.1, and 15–1612 15
Annotated Code of Maryland 16
(2017 Replacement Volume and 2024 Supplement) 17
BY adding to 18
Article – Insurance 19
Section 15–847.2 20
Annotated Code of Maryland 21
(2017 Replacement Volume and 2024 Supplement) 22
SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF M ARYLAND, 23
That the Laws of Maryland read as follows: 24
Article – Insurance 25
2 SENATE BILL 975
15–847. 1
(a) (1) In this section the following words have the meanings indicated. 2
(5) (i) “Specialty drug” means a prescription drug that: 3
1. is prescribed for an individual with a complex or chronic 4
medical condition or a rare medical condition; 5
2. costs $600 or more for up to a 30–day supply; 6
3. is not typically stocked at retail pharmacies; and 7
4. A. requires a difficult or unusual process of delivery to 8
the patient in the preparation, handling, storage, inventory, or distribution of the drug; or 9
B. requires enhanced patient education, management, or 10
support, beyond those required for traditional dispensing, before or after administration of 11
the drug. 12
(ii) “Specialty drug” does not include a prescription drug prescribed 13
to treat diabetes, HIV, or AIDS. 14
(d) Subject to § 15–805 of this subtitle [and], notwithstanding § 15–806 of this 15
subtitle, [nothing in] AND EXCEPT AS PROVID ED IN § 15–847.2 OF THIS SUBTITLE, this 16
article or regulations adopted under this article [precludes] DO NOT PRECLUDE an entity 17
subject to this section from requiring a covered specialty drug to be obtained through: 18
(1) a designated pharmacy or other source authorized under the Health 19
Occupations Article to dispense or administer prescription drugs; or 20
(2) a pharmacy participating in the entity’s provider network, if the entity 21
determines that the pharmacy: 22
(i) meets the entity’s performance standards; and 23
(ii) accepts the entity’s network reimbursement rates. 24
15–847.2. 25
(A) IN THIS SECTION, “SPECIALTY DRUG ” HAS THE MEANING STAT ED IN § 26
15–847 OF THIS SUBTITLE . 27
(B) (1) THIS SECTION APPLIES TO: 28
SENATE BILL 975 3
(I) INSURERS AND NONPROF IT HEALTH SERVICE PL ANS THAT 1
PROVIDE COVERAGE FOR PRESCRIPTION DRU GS UNDER INDIVIDUAL , GROUP, OR 2
BLANKET HEALTH INSUR ANCE POLICIES OR CON TRACTS THAT ARE ISSU ED OR 3
DELIVERED IN THE STATE; AND 4
(II) HEALTH MAINTENANCE O RGANIZATIONS THAT PR OVIDE 5
COVERAGE FOR PRESCRI PTION DRUGS UNDER IN DIVIDUAL OR GROUP CONTRACTS 6
THAT ARE ISSUED OR D ELIVERED IN THE STATE. 7
(2) AN INSURER, A NONPROFIT HEALTH S ERVICE PLAN, OR A HEALTH 8
MAINTENANCE ORGANIZA TION THAT PROVIDES C OVERAGE FOR PRESCRIP TION 9
DRUGS THROUGH A PHAR MACY BENEFITS MANAGE R IS SUBJECT TO THE 10
REQUIREMENT S OF THIS SECTION. 11
(C) AN ENTITY SUBJECT TO THIS SECTION MAY NOT EXCLUDE COVERAGE 12
FOR A COVERED SPECIA LTY DRUG ADMINISTERE D OR DISPENSED BY A PROVIDER 13
UNDER § 12–102 OF THE HEALTH OCCUPATIONS ARTICLE IF THE ENTITY 14
DETERMINES THAT: 15
(1) THE PROVIDER THAT ADMINISTERS OR DISPENSES THE COVERE D 16
SPECIALTY DRUG : 17
(I) IS AN IN–NETWORK PROVIDER OF COVERED MEDICAL 18
ONCOLOGY SERVICES ; AND 19
(II) COMPLIES WITH STATE REGULATIONS FOR THE 20
ADMINISTERING AND DISPENSING OF SPECIA LTY DRUGS; AND 21
(2) THE COVERED SPECIALTY DRUG IS : 22
(I) INFUSED, AUTO–INJECTED, OR AN ORAL TARGETED 23
IMMUNE MODULATOR ; OR 24
(II) AN ORAL MEDICATION T HAT: 25
1. REQUIRES COMPLEX DOS ING BASED ON CLINICA L 26
PRESENTATION ; OR 27
2. IS USED CONCOMITANTL Y WITH OTHER INFUSIO N OR 28
RADIATION THERAPIES. 29
(D) THE REIMBURSEMENT RAT E FOR SPECIALTY DRUG S COVERED UNDER 30
THIS SECTION SHALL B E: 31 4 SENATE BILL 975
(1) AGREED TO BY THE COVERED, IN–NETWORK PROVIDER AND THE 1
ENTITY SUBJECT TO TH IS SECTION; AND 2
(2) BILLED AT A NONHOSPI TAL LEVEL OF CARE OR PLACE OF 3
SERVICE. 4
(E) THIS SECTION DOES NOT PROHIBIT AN ENTITY SUBJECT TO THIS 5
SECTION FROM REFUSIN G TO AUTHORIZE OR AP PROVE OR FROM DENYIN G 6
COVERAGE FOR A COVERED SPECIALTY DRUG ADMINISTERED OR DISP ENSED BY A 7
PROVIDER IF ADMINIST ERING OR DISPENSING THE DRUG FAIL S TO SATISFY 8
MEDICAL NECESSITY CRITERIA. 9
15–1611.1. 10
(a) This section applies only to a pharmacy benefits manager that provides 11
pharmacy benefits management services on behalf of a carrier. 12
(b) Except as provided in subsection (c) of this section, a pharmacy benefits 13
manager may not require that a beneficiary use a specific pharmacy or entity to fill a 14
prescription if: 15
(1) the pharmacy benefits manager or a corporate affiliate of the pharmacy 16
benefits manager has an ownership interest in the pharmacy or entity; or 17
(2) the pharmacy or entity has an ownership interest in the pharmacy 18
benefits manager or a corporate affiliate of the pharmacy benefits manager. 19
(c) [A] EXCEPT AS PROVIDED IN § 15–847.2 OF THIS TITLE, A pharmacy 20
benefits manager may require a beneficiary to use a specific pharmacy or entity for a 21
specialty drug as defined in § 15–847 of this title. 22
15–1612. 23
(a) This section applies only to a pharmacy benefits manager that provides 24
pharmacy benefits management services on behalf of a carrier. 25
(b) This section does not apply to reimbursement: 26
(1) EXCEPT AS PROVIDED I N § 15–847.2 OF THIS TITLE, for specialty 27
drugs; 28
(2) for mail order drugs; or 29
(3) to a chain pharmacy with more than 15 stores or a pharmacist who is 30
an employee of the chain pharmacy. 31 SENATE BILL 975 5
(c) A pharmacy benefits manager may not reimburse a pharmacy or pharmacist 1
for a pharmaceutical product or pharmacist service in an amount less than the amount that 2
the pharmacy benefits manager reimburses itself or an affiliate for providing the same 3
product or service. 4
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all 5
policies, contracts, and health benefit plans issued, delivered, or renewed in the State on or 6
after January 1, 2026. 7
SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect 8
January 1, 2026. 9