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§ 15-854. Prior authorization for prescription drugs

West's Annotated Code of MarylandInsuranceEffective: January 1, 2024

West's Annotated Code of Maryland
Insurance (Refs & Annos)
Title 15. Health Insurance
Subtitle 8. Required Health Insurance Benefits (Refs & Annos)
Effective: January 1, 2024
MD Code, Insurance, § 15-854
§ 15-854. Prior authorization for prescription drugs
Applicability
(a)(1) This section applies to:
(i) insurers and nonprofit health service plans that provide coverage for prescription drugs through a pharmacy benefit under individual, group, or blanket health insurance policies or contracts that are issued or delivered in the State; and
(ii) health maintenance organizations that provide coverage for prescription drugs through a pharmacy benefit under individual or group contracts that are issued or delivered in the State.
(2) An insurer, a nonprofit health service plan, or a health maintenance organization that provides coverage for prescription drugs through a pharmacy benefits manager or that contracts with a private review agent under Subtitle 10B of this article is subject to the requirements of this section.
(3) This section does not apply to a managed care organization as defined in § 15-101 of the Health--General Article.
Request requirements
(b)(1)(i) If an entity subject to this section requires a prior authorization for a prescription drug, the prior authorization request shall allow a health care provider to indicate whether a prescription drug is to be used to treat a chronic condition.
(ii) If a health care provider indicates that the prescription drug is to treat a chronic condition, an entity subject to this section may not request a reauthorization for a repeat prescription for the prescription drug for 1 year or for the standard course of treatment for the chronic condition being treated, whichever is less.
(2) For a prior authorization that is filed electronically, the entity shall maintain a database that will prepopulate prior authorization requests with an insured's available insurance and demographic information.
Denial explanation
(c) If an entity subject to this section denies coverage for a prescription drug, the entity shall provide a detailed written explanation for the denial of coverage, including whether the denial was based on a requirement for prior authorization.
Honoring a prior authorization issued by previous entity
(d)(1) On receipt of information documenting a prior authorization from the insured or from the insured's health care provider, an entity subject to this section shall honor a prior authorization granted to an insured from a previous entity for at least the initial 30 days of an insured's prescription drug benefit coverage under the health benefit plan of the new entity.
(2) During the time period described in paragraph (1) of this subsection, an entity may perform its own review to grant a prior authorization for the prescription drug.
Honoring a prior authorization issued by entity
(e)(1) An entity subject to this section shall honor a prior authorization issued by the entity for a prescription drug:
(i) if the insured changes health benefit plans that are both covered by the same entity and the prescription drug is a covered benefit under the current health benefit plan; or
(ii) except as provided in paragraph (2) of this subsection, when the dosage for the approved prescription drug changes and the change is consistent with federal Food and Drug Administration labeled dosages.
(2) An entity may not be required to honor a prior authorization for a change in dosage for an opioid under this subsection.
Notice of new requirement for prior authorization
(f) If an entity under this section implements a new prior authorization requirement for a prescription drug, the entity shall provide notice of the new requirement at least 30 days before the implementation of a new prior authorization requirement:
(1) in writing to any insured who is prescribed the prescription drug; and
(2) either in writing or electronically to all contracted health care providers.
Different dosage strengths
(g)(1) Except as provided in paragraph (2) of this subsection, an entity subject to this section may not require more than one prior authorization if two or more tablets of different dosage strengths of the same prescription drug are:
(i) prescribed at the same time as part of an insured's treatment plan; and
(ii) manufactured by the same manufacturer.
(2) This subsection does not prohibit an entity from requiring more than one prior authorization if the prescription is for two or more tablets of different dosage strengths of an opioid that is not an opioid partial agonist.

Credits

Added by Acts 2019, c. 549, § 1, eff. Jan. 1, 2020. Amended by Acts 2023, c. 364, § 1, eff. Jan. 1, 2024; Acts 2023, c. 365, § 1, eff. Jan. 1, 2024.
MD Code, Insurance, § 15-854, MD INSURANCE § 15-854
Current through legislation effective through April 9, 2023, from the 2024 Regular Session of the General Assembly. Some statute sections may be more current, see credits for details.
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