Maryland 2025 Regular Session

Maryland Senate Bill SB975 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1
2	2
3	3		EXPLANATION: CAPITALS INDICATE MAT TER ADDED TO EXISTIN G LAW.
4	4		[Brackets] indicate matter deleted from existing law.
5		-	Underlining indicates amendments to bill.
6		-	Strike out indicates matter stricken from the bill by amendment or deleted from the law by
7		-	amendment.
8	5		sb0975
9	6
10	7		SENATE BILL 975
11	8		J5 5lr2643
12		-	CF ~~HB 1243~~
	9	+	CF 5lr2645
13	10		By: Senator Lam
14	11		Introduced and read first time: January 28, 2025
15	12		Assigned to: Finance
16		-	Committee Report: Favorable with amendments
17		-	Senate action: Adopted
18		-	Read second time: March 10, 2025
19	13
20		-	~~CHAPTER ______~~
	14	+	A BILL ENTITLED
21	15
22	16		AN ACT concerning 1
23	17
24	18		Health Insurance – Coverage for Specialty Drugs 2
25	19
26	20		FOR the purpose of prohibiting certain insurers, nonprofit health service plans, and health 3
27	21		maintenance organizations from excluding coverage for certain specialty drugs that 4
28	22		are administered or dispensed by a provider that meets certain criteria; requiring 5
29	23		the reimbursement rate for certain specialty drugs to meet certain criteria; and 6
30	24		generally relating to health insurance coverage for specialty drugs. 7
31	25
32	26		BY repealing and reenacting, without amendments, 8
33	27		Article – Insurance 9
34	28		Section 15–847(a)(1) and (5) 10
35	29		Annotated Code of Maryland 11
36	30		(2017 Replacement Volume and 2024 Supplement) 12
37	31
38	32		BY repealing and reenacting, with amendments, 13
39	33		Article – Insurance 14
40	34		Section 15–847(d), 15–1611.1, and 15–1612 15
41	35		Annotated Code of Maryland 16
42	36		(2017 Replacement Volume and 2024 Supplement) 17
43	37
44	38		BY adding to 18
45	39		Article – Insurance 19
46		-	Section ~~15–847(h) and~~ 15–847.2 20
	40	+	Section 15–847.2 20
47	41		Annotated Code of Maryland 21
48		-	(2017 Replacement Volume and 2024 Supplement) 22 2 SENATE BILL 975
	42	+	(2017 Replacement Volume and 2024 Supplement) 22
	43	+
	44	+	SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF M ARYLAND, 23
	45	+	That the Laws of Maryland read as follows: 24
	46	+
	47	+	Article – Insurance 25
	48	+	2 SENATE BILL 975
	49	+
	50	+
	51	+	15–847. 1
	52	+
	53	+	(a) (1) In this section the following words have the meanings indicated. 2
	54	+
	55	+	(5) (i) “Specialty drug” means a prescription drug that: 3
	56	+
	57	+	1. is prescribed for an individual with a complex or chronic 4
	58	+	medical condition or a rare medical condition; 5
	59	+
	60	+	2. costs $600 or more for up to a 30–day supply; 6
	61	+
	62	+	3. is not typically stocked at retail pharmacies; and 7
	63	+
	64	+	4. A. requires a difficult or unusual process of delivery to 8
	65	+	the patient in the preparation, handling, storage, inventory, or distribution of the drug; or 9
	66	+
	67	+	B. requires enhanced patient education, management, or 10
	68	+	support, beyond those required for traditional dispensing, before or after administration of 11
	69	+	the drug. 12
	70	+
	71	+	(ii) “Specialty drug” does not include a prescription drug prescribed 13
	72	+	to treat diabetes, HIV, or AIDS. 14
	73	+
	74	+	(d) Subject to § 15–805 of this subtitle [and], notwithstanding § 15–806 of this 15
	75	+	subtitle, [nothing in] AND EXCEPT AS PROVID ED IN § 15–847.2 OF THIS SUBTITLE, this 16
	76	+	article or regulations adopted under this article [precludes] DO NOT PRECLUDE an entity 17
	77	+	subject to this section from requiring a covered specialty drug to be obtained through: 18
	78	+
	79	+	(1) a designated pharmacy or other source authorized under the Health 19
	80	+	Occupations Article to dispense or administer prescription drugs; or 20
	81	+
	82	+	(2) a pharmacy participating in the entity’s provider network, if the entity 21
	83	+	determines that the pharmacy: 22
	84	+
	85	+	(i) meets the entity’s performance standards; and 23
	86	+
	87	+	(ii) accepts the entity’s network reimbursement rates. 24
	88	+
	89	+	15–847.2. 25
	90	+
	91	+	(A) IN THIS SECTION, “SPECIALTY DRUG ” HAS THE MEANING STAT ED IN § 26
	92	+	15–847 OF THIS SUBTITLE . 27
	93	+
	94	+	(B) (1) THIS SECTION APPLIES TO: 28
	95	+	SENATE BILL 975 3
	96	+
	97	+
	98	+	(I) INSURERS AND NONPROF IT HEALTH SERVICE PL ANS THAT 1
	99	+	PROVIDE COVERAGE FOR PRESCRIPTION DRU GS UNDER INDIVIDUAL , GROUP, OR 2
	100	+	BLANKET HEALTH INSUR ANCE POLICIES OR CON TRACTS THAT ARE ISSU ED OR 3
	101	+	DELIVERED IN THE STATE; AND 4
	102	+
	103	+	(II) HEALTH MAINTENANCE O RGANIZATIONS THAT PR OVIDE 5
	104	+	COVERAGE FOR PRESCRI PTION DRUGS UNDER IN DIVIDUAL OR GROUP CONTRACTS 6
	105	+	THAT ARE ISSUED OR D ELIVERED IN THE STATE. 7
	106	+
	107	+	(2) AN INSURER, A NONPROFIT HEALTH S ERVICE PLAN, OR A HEALTH 8
	108	+	MAINTENANCE ORGANIZA TION THAT PROVIDES C OVERAGE FOR PRESCRIP TION 9
	109	+	DRUGS THROUGH A PHAR MACY BENEFITS MANAGE R IS SUBJECT TO THE 10
	110	+	REQUIREMENT S OF THIS SECTION. 11
	111	+
	112	+	(C) AN ENTITY SUBJECT TO THIS SECTION MAY NOT EXCLUDE COVERAGE 12
	113	+	FOR A COVERED SPECIA LTY DRUG ADMINISTERE D OR DISPENSED BY A PROVIDER 13
	114	+	UNDER § 12–102 OF THE HEALTH OCCUPATIONS ARTICLE IF THE ENTITY 14
	115	+	DETERMINES THAT: 15
	116	+
	117	+	(1) THE PROVIDER THAT ADMINISTERS OR DISPENSES THE COVERE D 16
	118	+	SPECIALTY DRUG : 17
	119	+
	120	+	(I) IS AN IN–NETWORK PROVIDER OF COVERED MEDICAL 18
	121	+	ONCOLOGY SERVICES ; AND 19
	122	+
	123	+	(II) COMPLIES WITH STATE REGULATIONS FOR THE 20
	124	+	ADMINISTERING AND DISPENSING OF SPECIA LTY DRUGS; AND 21
	125	+
	126	+	(2) THE COVERED SPECIALTY DRUG IS : 22
	127	+
	128	+	(I) INFUSED, AUTO–INJECTED, OR AN ORAL TARGETED 23
	129	+	IMMUNE MODULATOR ; OR 24
	130	+
	131	+	(II) AN ORAL MEDICATION T HAT: 25
	132	+
	133	+	1. REQUIRES COMPLEX DOS ING BASED ON CLINICA L 26
	134	+	PRESENTATION ; OR 27
	135	+
	136	+	2. IS USED CONCOMITANTL Y WITH OTHER INFUSIO N OR 28
	137	+	RADIATION THERAPIES. 29
	138	+
	139	+	(D) THE REIMBURSEMENT RAT E FOR SPECIALTY DRUG S COVERED UNDER 30
	140	+	THIS SECTION SHALL B E: 31 4 SENATE BILL 975
49	141
50	142
51	143
52		-	~~SECTION 1.~~ ~~BE IT ENACTED~~ BY THE ~~GENERAL ASSEMBLY OF MARYLAND,~~ 1
53		-	~~That the Laws of Maryland read as follows:~~ 2
	144	+	(1) AGREED TO BY THE COVERED, IN–NETWORK PROVIDER AND THE 1
	145	+	ENTITY SUBJECT TO TH IS SECTION; AND 2
54	146
55		-	Article – Insurance 3
	147	+	(2) BILLED AT A NONHOSPI TAL LEVEL OF CARE OR PLACE OF 3
	148	+	SERVICE. 4
56	149
57		-	15–847. 4
	150	+	(E) THIS SECTION DOES NOT PROHIBIT AN ENTITY SUBJECT TO THIS 5
	151	+	SECTION FROM REFUSIN G TO AUTHORIZE OR AP PROVE OR FROM DENYIN G 6
	152	+	COVERAGE FOR A COVERED SPECIALTY DRUG ADMINISTERED OR DISP ENSED BY A 7
	153	+	PROVIDER IF ADMINIST ERING OR DISPENSING THE DRUG FAIL S TO SATISFY 8
	154	+	MEDICAL NECESSITY CRITERIA. 9
58	155
59		-	~~(a) (~~1~~) In this section the following words have the meanings indicated~~. 5
	156	+	15–1611.1. 10
60	157
61		-	(5) (i) “Specialty drug” means a prescription drug that: 6
	158	+	(a) This section applies only to a pharmacy benefits manager that provides 11
	159	+	pharmacy benefits management services on behalf of a carrier. 12
62	160
63		-	1. is prescribed for an individual with a complex or chronic 7
64		-	medical condition or a rare medical condition; 8
	161	+	(b) Except as provided in subsection (c) of this section, a pharmacy benefits 13
	162	+	manager may not require that a beneficiary use a specific pharmacy or entity to fill a 14
	163	+	prescription if: 15
65	164
66		-	2. costs $600 or more for up to a 30–day supply; 9
	165	+	(1) the pharmacy benefits manager or a corporate affiliate of the pharmacy 16
	166	+	benefits manager has an ownership interest in the pharmacy or entity; or 17
67	167
68		-	3. is not typically stocked at retail pharmacies; and 10
	168	+	(2) the pharmacy or entity has an ownership interest in the pharmacy 18
	169	+	benefits manager or a corporate affiliate of the pharmacy benefits manager. 19
69	170
70		-	4. A. requires a difficult or unusual process of delivery to 11
71		-	the patient in the preparation, handling, storage, inventory, or distribution of the drug; or 12
	171	+	(c) [A] EXCEPT AS PROVIDED IN § 15–847.2 OF THIS TITLE, A pharmacy 20
	172	+	benefits manager may require a beneficiary to use a specific pharmacy or entity for a 21
	173	+	specialty drug as defined in § 15–847 of this title. 22
72	174
73		-	B. requires enhanced patient education, management, or 13
74		-	support, beyond those required for traditional dispensing, before or after administration of 14
75		-	the drug. 15
	175	+	15–1612. 23
76	176
77		-	(ii) ~~“Specialty drug”~~ ~~does not include~~ a ~~prescription drug prescribed 16~~
78		-	~~to treat diabetes,~~ ~~HIV, or AIDS~~. 17
	177	+	(a) This section applies only to a pharmacy benefits manager that provides 24
	178	+	pharmacy benefits management services on behalf of a carrier. 25
79	179
80		-	(d) Subject to SUBSECTION (H) OF THIS SECTION AND § 15–805 of this subtitle 18
81		-	[and], notwithstanding § 15–806 of this subtitle, [nothing in] AND EXCEPT AS PROVID ED 19
82		-	IN § 15–847.2 OF THIS SUBTITLE , this article or regulations adopted under this article 20
83		-	[precludes] DO NOT PRECLUDE an entity subject to this section from requiring a covered 21
84		-	specialty drug to be obtained through: 22
	180	+	(b) This section does not apply to reimbursement: 26
85	181
86		-	(1) ~~a designated pharmacy or other source authorized under the Health 23~~
87		-	~~Occupations Article to dispense or administer prescription~~ drugs; ~~or 24~~
	182	+	(1) EXCEPT AS PROVIDED I N § 15–847.2 OF THIS TITLE, for specialty 27
	183	+	drugs; 28
88	184
89		-	(2) a pharmacy participating in the entity’s provider network, if the entity 25
90		-	determines that the pharmacy: 26
	185	+	(2) for mail order drugs; or 29
91	186
92		-	(i) meets the entity’s performance standards; and 27
93		-
94		-	(ii) accepts the entity’s network reimbursement rates. 28
95		-	SENATE BILL 975 3
96		-
97		-
98		-	(H) THIS SECTION MAY NOT BE CONSTRUED TO SUPE RSEDE THE AUTHORITY 1
99		-	OF THE HEALTH SERVICES COST REVIEW COMMISSION TO SET RAT ES FOR 2
100		-	SPECIALTY DRUGS ADMI NISTERED TO PATIENTS IN A SETTING REGULAT ED BY THE 3
101		-	HEALTH SERVICES COST REVIEW COMMISSION. 4
102		-
103		-	15–847.2. 5
104		-
105		-	(A) IN THIS SECTION, “SPECIALTY DRUG ” HAS THE MEAN ING STATED IN § 6
106		-	15–847 OF THIS SUBTITLE . 7
107		-
108		-	(B) (1) THIS SECTION APPLIES TO: 8
109		-
110		-	(I) INSURERS AND NONPROF IT HEALTH SERVICE PL ANS THAT 9
111		-	PROVIDE COVERAGE FOR PRESCRIPTION DRUGS U NDER INDIVIDUAL , GROUP, OR 10
112		-	BLANKET HEALTH INSUR ANCE POLICIES OR CON TRACTS THAT ARE ISSUED OR 11
113		-	DELIVERED IN THE STATE; AND 12
114		-
115		-	(II) HEALTH MAINTENANCE O RGANIZATIONS THAT PR OVIDE 13
116		-	COVERAGE FOR PRESCRI PTION DRUGS UNDER IN DIVIDUAL OR GROUP CO NTRACTS 14
117		-	THAT ARE ISSUED OR D ELIVERED IN THE STATE. 15
118		-
119		-	(2) AN INSURER, A NONPROFIT HEALTH S ERVICE PLAN, OR A HEALTH 16
120		-	MAINTENANCE ORGANIZA TION THAT PROVIDES C OVERAGE FOR PRESCRIP TION 17
121		-	DRUGS THROUGH A PHAR MACY BENEFITS MANAGE R IS SUBJECT TO THE 18
122		-	REQUIREMENTS OF THIS SECTION. 19
123		-
124		-	(C) AN ENTITY SUBJECT TO THIS SECTION MAY NOT EXCLUDE COVERAGE 20
125		-	FOR A COVERED SPECIA LTY DRUG ADMINISTERED OR DISPENSED BY A PROVI DER 21
126		-	UNDER § 12–102 OF THE HEALTH OCCUPATIONS ARTICLE IF THE ENTITY 22
127		-	DETERMINES THAT : 23
128		-
129		-	(1) THE PROVIDER THAT AD MINISTERS OR DISPENS ES THE COVERED 24
130		-	SPECIALTY DRUG : 25
131		-
132		-	(I) IS AN IN–NETWORK PROVIDER OF COVERED MEDICAL 26
133		-	ONCOLOGY SERVICES ; AND 27
134		-
135		-	(II) COMPLIES WITH STATE REGULATIONS FOR THE 28
136		-	ADMINISTERING AND DI SPENSING OF SPECIALT Y DRUGS; AND 29
137		-
138		-	(2) THE COVERED SPECIALT Y DRUG IS: 30
139		-
140		-	(I) INFUSED, AUTO–INJECTED, OR AN ORAL TARGETED 31
141		-	IMMUNE MODULATOR ; OR 32 4 SENATE BILL 975
	187	+	(3) to a chain pharmacy with more than 15 stores or a pharmacist who is 30
	188	+	an employee of the chain pharmacy. 31 SENATE BILL 975 5
142	189
143	190
144	191
145		-	(II) AN ORAL ME DICATION THAT : 1
	192	+	(c) A pharmacy benefits manager may not reimburse a pharmacy or pharmacist 1
	193	+	for a pharmaceutical product or pharmacist service in an amount less than the amount that 2
	194	+	the pharmacy benefits manager reimburses itself or an affiliate for providing the same 3
	195	+	product or service. 4
146	196
147		-	1. REQUIRES COMPLEX DOS ING BASED ON CLINICA L 2
148		-	PRESENTATION ; OR 3
	197	+	SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all 5
	198	+	policies, contracts, and health benefit plans issued, delivered, or renewed in the State on or 6
	199	+	after January 1, 2026. 7
149	200
150		-	2. IS USED CONCOMITANTL Y WITH OTHER INFUSIO N OR 4
151		-	RADIATION THERAPIES . 5
152		-
153		-	(D) (1) THE SUBJECT TO SUBSECTION (F) OF THIS SECTION , THE 6
154		-	REIMBURSEMENT RATE F OR SPECIALTY DRUGS COVERED UNDER THIS S ECTION 7
155		-	SHALL BE: 8
156		-
157		-	(1) (I) AGREED TO BY THE COV ERED, IN–NETWORK PROVIDER AND 9
158		-	THE ENTITY SUBJECT T O THIS SECTION; AND 10
159		-
160		-	(2) (II) BILLED AT A NONHOSPI TAL LEVEL OF CARE OR PLACE OF 11
161		-	SERVICE. 12
162		-
163		-	(2) UNLESS OTHERWISE AGRE ED TO BY THE COVERED, IN–NETWORK 13
164		-	PROVIDER AND THE ENT ITY SUBJECT TO THIS SECTION, THE REIMBURSEMENT RA TE 14
165		-	FOR SPECIALTY DRUGS COVERED UNDER THIS S ECTION MAY NOT EXCEE D THE RATE 15
166		-	APPLICABLE TO A DESI GNATED SPECIALTY PHA RMACY FOR DISPENSING THE 16
167		-	COVERED SPECIALTY DR UGS. 17
168		-
169		-	(E) THIS SECTION DOES NOT PROHIBIT AN ENTITY S UBJECT TO THIS 18
170		-	SECTION FROM REFUSIN G TO AUTHORIZE OR AP PROVE OR FROM DENYIN G 19
171		-	COVERAGE FOR A COVER ED SPECIALTY DRUG AD MINISTERED OR DISPEN SED BY A 20
172		-	PROVIDER IF ADMINIST ERING OR DISPENSING THE DRUG FAILS TO SA TISFY 21
173		-	MEDICAL NECESSITY CR ITERIA. 22
174		-
175		-	(F) THIS SECTION MAY NOT BE CONSTRUED TO SUPE RSEDE THE AUTHORITY 23
176		-	OF THE HEALTH SERVICES COST REVIEW COMMISSION TO SET RAT ES FOR 24
177		-	SPECIALTY DRUGS ADMI NISTERED TO PATIENTS IN A SETTING REGULAT ED BY THE 25
178		-	HEALTH SERVICES COST REVIEW COMMISSION. 26
179		-
180		-	15–1611.1. 27
181		-
182		-	(a) This section applies only to a pharmacy benefits manager that provides 28
183		-	pharmacy benefits management services on behalf of a carrier. 29
184		-
185		-	(b) Except as provided in subsection (c) of this section, a pharmacy benefits 30
186		-	manager may not require that a beneficiary use a specific pharmacy or entity to fill a 31
187		-	prescription if: 32
188		-	SENATE BILL 975 5
189		-
190		-
191		-	(1) the pharmacy benefits manager or a corporate affiliate of the pharmacy 1
192		-	benefits manager has an ownership interest in the pharmacy or entity; or 2
193		-
194		-	(2) the pharmacy or entity has an ownership interest in the pharmacy 3
195		-	benefits manager or a corporate affiliate of the pharmacy benefits manager. 4
196		-
197		-	(c) [A] EXCEPT AS PROVIDED IN § 15–847.2 OF THIS TITLE, A pharmacy 5
198		-	benefits manager may require a beneficiary to use a specific pharmacy or entity for a 6
199		-	specialty drug as defined in § 15–847 of this title. 7
200		-
201		-	15–1612. 8
202		-
203		-	(a) This section applies only to a pharmacy benefits manager that provides 9
204		-	pharmacy benefits management services on behalf of a carrier. 10
205		-
206		-	(b) This section does not apply to reimbursement: 11
207		-
208		-	(1) EXCEPT AS PROVIDED I N § 15–847.2 OF THIS TITLE, for specialty 12
209		-	drugs; 13
210		-
211		-	(2) for mail order drugs; or 14
212		-
213		-	(3) to a chain pharmacy with more than 15 stores or a pharmacist who is 15
214		-	an employee of the chain pharmacy. 16
215		-
216		-	(c) A pharmacy benefits manager may not reimburse a pharmacy or pharmacist 17
217		-	for a pharmaceutical product or pharmacist service in an amount less than the amount that 18
218		-	the pharmacy benefits manager reimburses itself or an affiliate for providing the same 19
219		-	product or service. 20
220		-
221		-	SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all 21
222		-	policies, contracts, and health benefit plans issued, delivered, or renewed in the State on or 22
223		-	after January 1, 2026. 23
224		-
225		-	SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect 24
226		-	January 1, 2026. 25
227		-
	201	+	SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect 8
	202	+	January 1, 2026. 9