(2) THE MEMBER IS IN THE MIDST OF A COURSE OF TREATMENT WITH
THE PRESCRIPTION DRUG OR DEVICE THAT IS NOT IN THE FORMULARY; OR

(3) AN EQUIVALENT PRESCRIPTION DRUG OR DEVICE IN THE ENTITY'S
FORMULARY:

(I) HAS BEEN INEFFECTIVE IN TREATING THE DISEASE OR
CONDITION OF THE MEMBER; OR

(II) HAS CAUSED OR IS LIKELY TO CAUSE AN ADVERSE REACTION
OR OTHER HARM TO THE MEMBER.

(E) A MEMBER WHO OBTAINS A PRESCRIPTION DRUG OR DEVICE UNDER THIS
SECTION MAY NOT BE REQUIRED TO PAY ANY FEE OR COPAYMENT OTHER THAN
THAT REQUIRED FOR A PRESCRIPTION DRUG OR DEVICE IN THE FORMULARY.

(F) A DECISION BY A CARRIER TO NOT PROVIDE ACCESS TO OR COVERAGE OF
A PRESCRIPTION DRUG OR DEVICE UNDER THE PROCEDURE REQUIRED UNDER THIS
SECTION CONSTITUTES AN ADVERSE DECISION AS DEFINED UNDER SUBTITLE 10A
OF THIS TITLE.

(E) A DECISION BY AN ENTITY SUBJECT TO THIS SECTION NOT TO PROVIDE
ACCESS TO OR COVERAGE OF A PRESCRIPTION DRUG OR DEVICE IN ACCORDANCE
WITH THIS SECTION CONSTITUTES AN ADVERSE DECISION AS DEFINED UNDER
SUBTITLE 10A OF THIS TITLE IF THE DECISION IS BASED ON A FINDING THAT THE
PROPOSED DRUG OR DEVICE IS NOT MEDICALLY NECESSARY, APPROPRIATE, OR
EFFICIENT.

15-10A-09.

(b) In addition to the requirements of subsection (a) of this section, [on or
before January 1, 1999,] the Commissioner shall adopt by regulation a requirement
that each carrier provide a mechanism in a form and manner that the Commissioner
may require to enable a member to:

(1) be informed of the member's right to challenge a decision made by a
carrier that resulted in the nonpayment of a health care service; AND

(2) ACCESS THE CONSUMER EDUCATION AND ADVOCACY PROGRAM IN
THE ADMINISTRATION.

SECTION 2. AND BE IT FURTHER ENACTED, That the Laws of Maryland
read as follows:

Article - Insurance

15-831.

(A) IN THIS SECTION, " MASTECTOMY" MEANS THE SURGICAL REMOVAL OF
ALL OR PART OF A BREAST AS A RESULT OF BREAST CANCER

(B) THIS SECTION APPLIES TO: