Health Insurance - Coverage for Specialty Drugs
SB975 expands health insurance protections for certain specialty drugs in Maryland. The bill prohibits insurers, nonprofit health service plans, and health maintenance organizations from excluding coverage for covered specialty drugs when those drugs are administered or dispensed by an in-network provider that meets state regulatory requirements. It applies to specialty drugs used for complex, chronic, or rare conditions, with specific coverage rules for infused drugs, auto-injectables, oral targeted immune modulators, and certain oral medications used with infusion or radiation therapy.
The bill also limits how carriers and pharmacy benefits managers can steer patients to particular pharmacies for specialty drugs. It preserves some existing network and designated-pharmacy rules, but creates an exception requiring coverage when the provider is an in-network oncology provider and the drug meets the bill’s criteria. It further requires reimbursement for covered specialty drugs to be agreed to by the provider and carrier, billed at a nonhospital level of care, and not exceed the rate paid to a designated specialty pharmacy unless otherwise agreed. The law does not override the Health Services Cost Review Commission’s authority over rates in regulated settings.
The bill amends Maryland Insurance Article provisions governing specialty drugs and pharmacy benefits managers, including sections that previously allowed PBMs to require use of a specific pharmacy for specialty drugs and to exclude specialty drugs from certain reimbursement rules. It adds new section 15-847.2 and modifies related PBM statutes so those rules now yield to the new specialty-drug coverage protections. The act applies to policies and contracts issued, delivered, or renewed on or after January 1, 2026.
Overall sentiment appears strongly favorable. The bill passed the Senate unanimously and the House overwhelmingly, indicating broad bipartisan support and little visible opposition in the recorded votes. The lack of committee transcript material suggests no major recorded controversy in the available context.
The main points of potential contention are the bill’s impact on insurer and pharmacy benefit manager network controls, reimbursement rates, and specialty pharmacy steering. Carriers and PBMs may view the measure as limiting their ability to manage costs and direct utilization, while providers and patients—especially oncology patients and those needing complex specialty medications—are likely to benefit from broader access and fewer coverage barriers.
SB975 changes Maryland insurance law by creating a new specialty-drug coverage mandate and narrowing the ability of insurers, nonprofit health service plans, HMOs, and pharmacy benefits managers to exclude or channel coverage for certain specialty drugs. It amends Insurance Article §§ 15-847, 15-1611.1, and 15-1612 and adds § 15-847.2, affecting coverage, network pharmacy requirements, and reimbursement rules for specialty medications. The law applies to health benefit plans issued, delivered, or renewed on or after January 1, 2026, and preserves the Health Services Cost Review Commission’s authority in regulated settings.
The recorded legislative sentiment is strongly positive and largely noncontroversial. The bill passed the Senate 47-0 and the House 133-2, suggesting broad bipartisan agreement that the measure addresses access to specialty drugs without provoking significant opposition in floor votes. No committee transcript was provided, so the available record shows support but little detailed debate.
The likely areas of contention are the bill’s restrictions on insurer and PBM control over specialty-drug distribution and reimbursement. Opponents, if any, would most likely be carriers and pharmacy benefit managers concerned about reduced formulary/network management, higher costs, and limits on steering patients to designated specialty pharmacies. Supporters would be patients, oncology providers, and advocates for access who favor coverage when drugs are administered or dispensed by qualified in-network providers. The bill also carefully preserves medical-necessity denials and HSCRC rate-setting authority, which may have been included to address concerns about overreach.