Maryland Medical Assistance Program - Coverage for the Treatment of Obesity - Authorization
HB 813 revises Maryland’s pharmacy benefits reimbursement rules for the Maryland Medical Assistance Program and for pharmacy benefits managers (PBMs) that contract with pharmacies on behalf of managed care organizations. The bill changes reimbursement from a cost-based framework to a floor tied to the National Average Drug Acquisition Cost (NADAC) plus the fee-for-service professional dispensing fee determined by the Maryland Department of Health using the most recent in-state cost-of-dispensing survey. It also specifies that these minimum reimbursement rules do not apply to pharmacies owned by or affiliated with a PBM, or to mail-order pharmacies.
The bill also expands the definition of “purchaser” under Maryland’s PBM law to include insurers, nonprofit health service plans, and health maintenance organizations, with a narrow exclusion for certain nonprofit group-model HMOs using internal pharmacy operations. In addition, it requires the Maryland Insurance Administration and the Maryland Department of Health, in consultation with the Prescription Drug Affordability Board, to convene a stakeholder workgroup to study PBM-related issues and report interim and final findings to the General Assembly by the end of 2025 and 2026, respectively.
HB 813 amends the Health-General and Insurance Articles to set a new reimbursement benchmark for Medicaid and managed-care pharmacy claims, broadening the reach of Maryland’s PBM reimbursement rules and extending them to managed care organizations using PBMs. It also enlarges the set of entities covered by the state’s PBM purchaser definition, which may subject more commercial health plans and insurers to PBM regulation. The bill creates a formal study process that could lead to future statutory changes on pharmacy reimbursement, specialty drugs, anti-steering, transparency, ERISA-related issues, and PBM oversight.
The bill appears to have been viewed as a policy response to pharmacy reimbursement and drug pricing concerns, with a strong emphasis on protecting pharmacy access and improving payment adequacy. Its emergency status and enactment suggest legislative urgency and broad enough support to move quickly through the process. The workgroup provisions also indicate an interest in continuing stakeholder review rather than relying solely on immediate regulatory changes.
The main points of contention are likely the reimbursement floor and the exclusion of PBM-owned pharmacies and mail-order pharmacies from the new minimum payment rules. Community pharmacies and independent pharmacies are likely to support higher reimbursement tied to NADAC plus dispensing fees, while PBMs, managed care organizations, and some insurers may object to higher costs, reduced flexibility, or expanded regulation. The workgroup’s mandate to examine ERISA exemptions, specialty drug definitions, anti-steering, and commercial-versus-Medicaid cost differences suggests these are the most disputed policy areas.