PARRIS N. GLENDENING, Governor

Ch. 35

Defined terms: "Commissioner" § 1-101
"Health insurance" § 1-101
"Person" § 1-101
"Policy" § 1-101

15-805. REIMBURSEMENT FOR PHARMACEUTICAL PRODUCTS.

(A) DEFINITIONS.

(1) IN THIS SECTION THE FOLLOWING WORDS HAVE THE MEANINGS
INDICATED.

(2) "AUTHORIZED PRESCRIBER" MEANS A LICENSED DENTIST,
LICENSED PHYSICIAN, OR LICENSED PODIATRIST WHO IS AUTHORIZED UNDER THE
HEALTH OCCUPATIONS ARTICLE TO PRESCRIBE A PHARMACEUTICAL PRODUCT.

(3) "PHARMACEUTICAL PRODUCT" MEANS A DRUG OR MEDICINE THAT
MAY BE PRESCRIBED BY AN AUTHORIZED PRESCRIBER.

(B) SCOPE OF SECTION.

THIS SECTION DOES NOT APPLY TO A POLICY OR CONTRACT THAT IS ISSUED
TO AN EMPLOYER UNDER A COLLECTIVE BARGAINING AGREEMENT.

(C) AMOUNT OF REIMBURSEMENT.

(1) THIS SUBSECTION APPLIES TO EACH POLICY OR CONTRACT THAT IS
ISSUED OR DELIVERED IN THE STATE TO AN EMPLOYER OR INDIVIDUAL BY AN
INSURER OR NONPROFIT HEALTH SERVICE PLAN AND THAT PROVIDES GROUP OR
INDIVIDUAL HOSPITAL, MEDICAL, OR SURGICAL BENEFITS.

(2) A POLICY OR CONTRACT SUBJECT TO THIS SUBSECTION THAT
PROVIDES REIMBURSEMENT FOR A PHARMACEUTICAL PRODUCT PRESCRIBED BY
AN AUTHORIZED PRESCRIBER MAY NOT ESTABLISH THE AMOUNT OF
REIMBURSEMENT TO THE INSURED OR THE INSURED'S BENEFICIARY, INCLUDING
COPAYMENTS AND DEDUCTIBLES, BASED ON THE IDENTITY, PRACTICING
SPECIALTY, OR OCCUPATION OF THE AUTHORIZED PRESCRIBER.

(D) COPAYMENTS OR OTHER CONDITIONS PROHIBITED.

(1) THIS SUBSECTION APPLIES TO EACH INDIVIDUAL OR GROUP POLICY
OR CONTRACT THAT IS ISSUED OR DELIVERED IN THE STATE TO AN EMPLOYER OR
INDIVIDUAL BY AN INSURER OR NONPROFIT HEALTH SERVICE PLAN AND THAT
PROVIDES BENEFITS FOR PHARMACEUTICAL PRODUCTS.

(2) A POLICY OR CONTRACT SUBJECT TO THIS SUBSECTION MAY NOT
IMPOSE A COPAYMENT, DEDUCTIBLE, OR OTHER CONDITION ON AN INSURED OR
CERTIFICATE HOLDER WHO USES THE SERVICES OF A COMMUNITY PHARMACY
THAT IS NOT IMPOSED WHEN THE INSURED OR CERTIFICATE HOLDER USES THE
SERVICES OF A MAIL ORDER PHARMACY, IF THE BENEFITS ARE PROVIDED UNDER
THE SAME PROGRAM, POLICY, OR CONTRACT.

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