15-830.

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

(2) "AUTHORIZED PRESCRIBER" HAS THE MEANING STATED IN § 12-101
OF THE HEALTH OCCUPATIONS ARTICLE.

(2) (3) "FORMULARY" MEANS A LIST OF PRESCRIPTION DRUGS OR
DEVICES THAT ARE COVERED BY AN ENTITY SUBJECT TO THIS SECTION.

(3) (4) (I) "MEMBER" MEANS AN INDIVIDUAL ENTITLED TO HEALTH
CARE BENEFITS FOR PRESCRIPTION DRUGS OR DEVICES UNDER A POLICY ISSUED OR
DELIVERED IN THE STATE BY AN ENTITY SUBJECT TO THIS SECTION.

(II) "MEMBER" INCLUDES A SUBSCRIBER

(B) (1) THIS SECTION APPLIES TO:

(I) INSURERS AND NONPROFIT HEALTH SERVICE PLANS THAT
PROVIDE COVERAGE FOR PRESCRIPTION DRUGS AND DEVICES UNDER HEALTH
INSURANCE POLICIES OR CONTRACTS THAT ARE ISSUED OR DELIVERED IN THE
STATE; AND

(II) HEALTH MAINTENANCE ORGANIZATIONS THAT PROVIDE
COVERAGE FOR PRESCRIPTION DRUGS AND DEVICES UNDER CONTRACTS THAT ARE
ISSUED OR DELIVERED IN THE STATE.

(2) AN INSURER NONPROFIT HEALTH SERVICE PLAN, OR HEALTH
MAINTENANCE ORGANIZATION THAT PROVIDES COVERAGE FOR PRESCRIPTION
DRUGS AND DEVICES THROUGH A PHARMACY BENEFIT MANAGER IS SUBJECT TO
THE REQUIREMENTS OF THIS SECTION.

(2) (3) THIS SECTION DOES NOT APPLY TO A MANAGED CARE
ORGANIZATION AS DEFINED IN § 15-101 OF THE HEALTH - GENERAL ARTICLE.

(C) EACH ENTITY SUBJECT TO THIS SECTION THAT LIMITS ITS COVERAGE OF
PRESCRIPTION DRUGS OR DEVICES TO THOSE IN A FORMULARY SHALL ESTABLISH
AND IMPLEMENT A PROCEDURE BY WHICH A MEMBER MAY RECEIVE A
PRESCRIPTION DRUG OR DEVICE THAT IS NOT IN THE ENTITY'S FORMULARY IN
ACCORDANCE WITH THIS SECTION.

(D) THE PROCEDURE SHALL PROVIDE FOR COVERAGE FOR A PRESCRIPTION
DRUG OR DEVICE THAT IS NOT IN THE FORMULARY IF, IN THE JUDGMENT OF THE
PHYSICIAN WHO IS CARING FOR THE MEMBER AUTHORIZED PRESCRIBER:

(1) (I) THE PRESCRIPTION DRUG OR DEVICE THAT IS NOT IN THE
FORMULARY IS MEDICALLY NECESSARY; AND

(II) THERE IS NO EQUIVALENT PRESCRIPTION DRUG OR DEVICE IN
THE ENTITY'S FORMULARY; OR