HOUSE BILL 1005
C3

6lr1505
CF SB 848

By: Delegates Kelly, Anderson, Angel, Atterbeary, Barkley, B. Barnes, Barron,
Barve, Branch, Brooks, Busch, Carr, Clippinger, Cullison, Davis, Dumais,
Ebersole, Fennell, Fraser–Hidalgo, Frick, Frush, Gaines, Gilchrist, Glenn,
Gutierrez, Hettleman, Hill, Hixson, Holmes, Jackson, Jones, Kaiser,
Korman, Kramer, Krimm, Lafferty, Lam, Lierman, Lisanti, Luedtke,
McCray, McIntosh, A. Miller, Moon, Morales, Morhaim, Oaks, Patterson,
Pena–Melnyk, Pendergrass, Platt, Reznik, B. Robinson, S. Robinson,
Rosenberg, Sample–Hughes, Sanchez, Smith, Tarlau, Turner, Valderrama,
Vallario, Vaughn, Waldstreicher, Walker, A. Washington, M. Washington,
K. Young, and P. Young P. Young, Hammen, and Bromwell
Introduced and read first time: February 10, 2016
Assigned to: Health and Government Operations
Committee Report: Favorable with amendments
House action: Adopted
Read second time: March 13, 2016
CHAPTER ______
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AN ACT concerning

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Health Insurance – Contraceptive Equity Act

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FOR the purpose of prohibiting certain insurers, nonprofit health service plans, and health
maintenance organizations from applying a copayment, coinsurance, or prior
authorization requirement for certain contraceptive drugs and devices; providing
that the prohibition does not apply with respect to a certain health benefit plan;
requiring a certain insurer, nonprofit health service plan, and health maintenance
organization to post its contraceptive formulary on its Web site in a certain format,
include certain information on the formulary, and provide a print copy of the
formulary on request; establishing an exception to the prohibition against applying
a copayment or coinsurance requirement for certain contraceptive drugs or devices;
requiring a certain insurer, nonprofit health service plan, and health maintenance
organization to provide coverage for a single dispensing to an insured or an enrollee
of a certain supply of prescription contraceptives, except for certain prescriptions, for
a certain period of time subject to certain exceptions; requiring the insurer, nonprofit
health service plan, and health maintenance organization to increase the dispensing
EXPLANATION: CAPITALS INDICATE MATTER ADDED TO EXISTING LAW.
[Brackets] indicate matter deleted from existing law.
Underlining indicates amendments to bill.
Strike out indicates matter stricken from the bill by amendment or deleted from the law by
amendment.

*hb1005*

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HOUSE BILL 1005

fee paid to certain individuals the pharmacist under certain circumstances; requiring
a certain the insurer, nonprofit health service plan, and health maintenance
organization to provide coverage without a prescription for certain contraceptive
drugs, subject to certain limitations; prohibiting the insurer, nonprofit health service
plan, and health maintenance organizations organization from applying a
copayment or coinsurance requirement for the contraceptive drugs dispensed
without a prescription that exceeds a certain copayment or coinsurance requirement;
requiring certain insurers, nonprofit health service plans, and health maintenance
organizations to provide coverage for male sterilization; excluding a certain
organization from the requirement to provide the coverage for male sterilization;
prohibiting certain insurers, nonprofit health service plans, and health maintenance
organizations from applying a copayment, coinsurance requirement, or deductible to
coverage for male sterilization; providing that the prohibition does not apply with
respect to a certain health benefit plan; altering the circumstances under which a
member may receive a prescription drug or device that is not on the formulary of a
certain insurer, nonprofit health service plan, or health maintenance organization;
requiring the procedure under which a member may receive a prescription drug or
device that is not on the formulary to provide for coverage of a contraceptive
prescription drug or device that is medically necessary for adherence purposes the
member to adhere to the appropriate use of the prescription drug or device;
prohibiting the Maryland Medical Assistance Program and the Maryland Children’s
Health Program from applying a prior authorization requirement for certain
contraceptive drugs and devices; requiring the Maryland Medical Assistance
Program and the Maryland Children’s Health Program to provide coverage for a
single dispensing to an enrollee of a certain supply of prescription contraceptives,
subject to a certain exception; defining a certain term; providing for the application
of this Act; providing for a delayed effective date; and generally relating to health
insurance coverage of contraceptive drugs, devices, and procedures and
contraception equity.

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BY adding to
Article – Insurance
Section 15–826.1 and 15–826.2
Annotated Code of Maryland
(2011 Replacement Volume and 2015 Supplement)

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BY repealing and reenacting, with amendments,
Article – Insurance
Section 15–831
Annotated Code of Maryland
(2011 Replacement Volume and 2015 Supplement)

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BY adding to
Article – Health – General
Section 15–148
Annotated Code of Maryland
(2015 Replacement Volume)

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SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND,
That the Laws of Maryland read as follows:

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Article – Insurance

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15–826.1.
(A)

IN THIS SECTION, “AUTHORIZED PRESCRIBER” HAS THE MEANING
STATED IN § 12–101 OF THE HEALTH OCCUPATIONS ARTICLE.
(B)

THIS SECTION APPLIES TO:
(1)

INSURERS AND NONPROFIT HEALTH SERVICE PLANS THAT
PROVIDE COVERAGE FOR CONTRACEPTIVE DRUGS AND DEVICES UNDER
INDIVIDUAL, GROUP, OR BLANKET HEALTH INSURANCE POLICIES OR CONTRACTS
THAT ARE ISSUED OR DELIVERED IN THE STATE; AND

(2)

HEALTH
MAINTENANCE
ORGANIZATIONS
THAT
PROVIDE
COVERAGE FOR CONTRACEPTIVE DRUGS AND DEVICES UNDER INDIVIDUAL OR
GROUP CONTRACTS THAT ARE ISSUED OR DELIVERED IN THE STATE.

(C)

(1)

EXCEPT WITH RESPECT THIS SUBSECTION DOES NOT APPLY TO A
HEALTH BENEFIT PLAN THAT IS A GRANDFATHERED HEALTH PLAN, AS DEFINED IN
§ 1251 OF THE AFFORDABLE CARE ACT, AN.
(2)

AN ENTITY SUBJECT TO THIS SECTION:

(I)
EXCEPT FOR A DRUG OR DEVICE FOR WHICH THE U.S. FOOD
AND DRUG ADMINISTRATION HAS ISSUED A BLACK BOX WARNING, MAY NOT APPLY
A PRIOR AUTHORIZATION REQUIREMENT FOR A CONTRACEPTIVE DRUG OR DEVICE
THAT IS:

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1.

A.

AN INTRAUTERINE DEVICE; OR

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B.

AN IMPLANTABLE ROD;

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2.

APPROVED

BY

THE

U.S.

FOOD

AND

DRUG

ADMINISTRATION; AND
3.

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OBTAINED UNDER A PRESCRIPTION WRITTEN BY AN
AUTHORIZED PRESCRIBER; AND

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(1) (II) EXCEPT AS PROVIDED IN PARAGRAPH (3) OF THIS
SUBSECTION, MAY NOT APPLY A COPAYMENT, COINSURANCE, OR PRIOR

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HOUSE BILL 1005

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AUTHORIZATION
COPAYMENT
OR
COINSURANCE
CONTRACEPTIVE DRUG OR DEVICE THAT IS:

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(I)
1.
ADMINISTRATION; AND

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(II)

APPROVED

BY

THE

REQUIREMENT

U.S.

FOOD

AND

FOR

A

DRUG

2.

OBTAINED UNDER A PRESCRIPTION WRITTEN BY AN
AUTHORIZED PRESCRIBER; BUT.

(2) (3)

AN ENTITY SUBJECT TO THIS SECTION MAY APPLY A

COPAYMENT OR COINSURANCE REQUIREMENT FOR A CONTRACEPTIVE DRUG OR
DEVICE THAT, ACCORDING TO THE U.S. FOOD AND DRUG ADMINISTRATION, IS
THERAPEUTICALLY EQUIVALENT TO ANOTHER CONTRACEPTIVE DRUG OR DEVICE
THAT IS AVAILABLE UNDER THE SAME POLICY OR CONTRACT WITHOUT A
COPAYMENT OR COINSURANCE REQUIREMENT.

(D)

AN ENTITY SUBJECT TO THIS SECTION SHALL:

(1) (I)
POST ON ITS WEB SITE ITS CONTRACEPTIVE FORMULARY IN
A CONSUMER–FRIENDLY FORMAT THAT IS ACCESSIBLE TO INDIVIDUALS SEEKING
INFORMATION ABOUT COVERAGE FOR CONTRACEPTIVE DRUGS AND DEVICES
UNDER THE POLICIES OR CONTRACTS OF THE ENTITY; AND

(II)

INCLUDE IN THE FORMULARY COMPLETE AND CURRENT
INFORMATION ABOUT COST–SHARING REQUIREMENTS FOR CONTRACEPTIVE DRUGS
AND DEVICES ON AND OFF THE ENTITY’S FORMULARY; AND

(2)

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PROVIDE A PRINT COPY OF THE CONTRACEPTIVE FORMULARY
REQUIRED UNDER ITEM (1) OF THIS SUBSECTION ON REQUEST.

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(E) (D)
(1) EXCEPT AS PROVIDED IN PARAGRAPH (2) PARAGRAPHS (2)
AND (3) OF THIS SUBSECTION, AN ENTITY SUBJECT TO THIS SECTION SHALL
PROVIDE COVERAGE FOR A SINGLE DISPENSING TO AN INSURED OR AN ENROLLEE
OF A SUPPLY OF PRESCRIPTION CONTRACEPTIVES FOR A 13–MONTH 6–MONTH
PERIOD.

(2)

SUBJECT TO § 15–824 OF THIS SUBTITLE, AN ENTITY SUBJECT TO

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THIS SECTION MAY PROVIDE COVERAGE FOR A SUPPLY OF PRESCRIPTION
CONTRACEPTIVES THAT IS FOR LESS THAN A 6–MONTH PERIOD, IF A 6–MONTH
SUPPLY WOULD EXTEND BEYOND THE PLAN YEAR.

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(2) (3)
PARAGRAPH (1) OF THIS SUBSECTION DOES NOT APPLY TO
THE FIRST 2–MONTH SUPPLY OF PRESCRIPTION CONTRACEPTIVES DISPENSED TO
AN INSURED OR AN ENROLLEE UNDER:

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(I)
THE
CONTRACEPTIVES; OR

FIRST

PRESCRIPTION

FOR

THE

(II)

ANY SUBSEQUENT PRESCRIPTION FOR A CONTRACEPTIVE
THAT IS DIFFERENT THAN THE LAST CONTRACEPTIVE DISPENSED TO OR CHANGE IN
A PRESCRIPTION FOR CONTRACEPTIVES FOR THE INSURED OR THE ENROLLEE.

(3) (4)

WHENEVER AN ENTITY SUBJECT TO THIS SECTION

INCREASES THE COPAYMENT FOR A SINGLE DISPENSING OF A SUPPLY OF
PRESCRIPTION CONTRACEPTIVES FOR A 13–MONTH 6–MONTH PERIOD, THE ENTITY
SHALL ALSO INCREASE PROPORTIONATELY THE DISPENSING FEE PAID TO THE
PHARMACIST OR OTHER INDIVIDUAL AUTHORIZED BY LAW TO DISPENSE
PRESCRIPTION CONTRACEPTIVES.

(F) (E)

AN SUBJECT TO PARAGRAPH (2) OF THIS SUBSECTION, AN
ENTITY SUBJECT TO THIS SECTION:

(1)

(1)

(I)

(2)

(II)

(2)

AN ENTITY SUBJECT TO THIS SECTION:

SHALL PROVIDE COVERAGE WITHOUT A PRESCRIPTION FOR
ALL CONTRACEPTIVE DRUGS APPROVED BY THE U.S. FOOD AND DRUG
ADMINISTRATION AND AVAILABLE BY PRESCRIPTION AND OVER THE COUNTER; AND
MAY NOT APPLY A COPAYMENT OR COINSURANCE
REQUIREMENT FOR A CONTRACEPTIVE DRUG DISPENSED WITHOUT A
PRESCRIPTION UNDER ITEM (I) OF THIS PARAGRAPH THAT EXCEEDS THE
COPAYMENT OR COINSURANCE REQUIREMENT FOR THE CONTRACEPTIVE DRUG
DISPENSED UNDER A PRESCRIPTION.

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INITIAL

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(I)

MAY ONLY BE REQUIRED TO PROVIDE POINT–OF–SALE
COVERAGE UNDER PARAGRAPH (1)(I) OF THIS SUBSECTION AT IN–NETWORK
PHARMACIES; AND

(II)

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MAY LIMIT THE FREQUENCY WITH WHICH THE COVERAGE
REQUIRED UNDER PARAGRAPH (1)(I) OF THIS SUBSECTION IS PROVIDED.

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15–826.2.

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(A)

(1)

IN THIS SUBSECTION, “GROUP” MEANS A GROUP THAT IS NOT A

GROUP COVERED UNDER A HEALTH INSURANCE POLICY OR CONTRACT OR UNDER A
HEALTH MAINTENANCE ORGANIZATION CONTRACT ISSUED OR DELIVERED TO A
SMALL EMPLOYER, AS DEFINED IN § 31–101 OF THIS ARTICLE.

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HOUSE BILL 1005

(2)

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THIS SUBSECTION APPLIES TO:

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(I)
INSURERS AND NONPROFIT HEALTH SERVICE PLANS THAT
PROVIDE HOSPITAL, MEDICAL, OR SURGICAL BENEFITS TO GROUPS ON AN
EXPENSE–INCURRED BASIS UNDER HEALTH INSURANCE POLICIES OR CONTRACTS
THAT ARE ISSUED OR DELIVERED IN THE STATE; AND

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(II) HEALTH MAINTENANCE ORGANIZATIONS THAT PROVIDE
HOSPITAL, MEDICAL, OR SURGICAL BENEFITS TO GROUPS UNDER CONTRACTS THAT
ARE ISSUED OR DELIVERED IN THE STATE.

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(3)

THIS SUBSECTION DOES NOT APPLY TO AN ORGANIZATION THAT
REQUESTS AND RECEIVES AN EXCLUSION FROM COVERAGE UNDER § 15–826(C) OF
THIS SUBTITLE.
(4)

AN ENTITY SUBJECT TO THIS SUBSECTION SHALL PROVIDE
COVERAGE FOR MALE STERILIZATION.
(B)

(1)

THIS SUBSECTION APPLIES TO:
(I)

INSURERS AND NONPROFIT HEALTH SERVICE PLANS THAT
PROVIDE COVERAGE FOR MALE STERILIZATION 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 MALE STERILIZATION UNDER INDIVIDUAL OR GROUP CONTRACTS
THAT ARE ISSUED OR DELIVERED IN THE STATE.

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EXCEPT WITH RESPECT TO A HEALTH BENEFIT PLAN THAT IS A
GRANDFATHERED HEALTH PLAN, AS DEFINED IN § 1251 OF THE AFFORDABLE CARE
ACT, AN ENTITY SUBJECT TO THIS SUBSECTION MAY NOT APPLY A COPAYMENT,
COINSURANCE REQUIREMENT, OR DEDUCTIBLE TO COVERAGE FOR MALE
STERILIZATION.

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15–831.

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(2)

(a)

(1)

In this section the following words have the meanings indicated.

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(2)
“Authorized prescriber” has the meaning stated in § 12–101 of the
Health Occupations Article.

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(3)
“Formulary” means a list of prescription drugs or devices that are
covered by an entity subject to this section.

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(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.

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(ii)
(b)

(1)

“Member” includes a subscriber.

This section applies to:

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(i)
insurers and nonprofit health service plans that provide coverage
for prescription drugs and devices under individual, group, or blanket health insurance
policies or contracts that are issued or delivered in the State; and

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(ii)
health maintenance organizations that provide coverage for
prescription drugs and devices under individual or group contracts that are issued or
delivered in the State.

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(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.

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(3)
This section does not apply to a managed care organization as defined
in § 15–101 of the Health – General Article.

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(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.

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(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 authorized prescriber:

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(1)
formulary; [or]

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(2)

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there is no equivalent prescription drug or device in the entity’s

an equivalent prescription drug or device in the entity’s formulary:
(i)

has been ineffective in treating the disease or condition of the

(ii)

has caused or is likely to cause an adverse reaction or other harm

member; or
to the member; OR

(3)

FOR A CONTRACEPTIVE PRESCRIPTION DRUG OR DEVICE, THE
PRESCRIPTION DRUG OR DEVICE THAT IS NOT ON THE FORMULARY IS MEDICALLY
NECESSARY FOR ADHERENCE PURPOSES THE MEMBER TO ADHERE TO THE
APPROPRIATE USE OF THE PRESCRIPTION DRUG OR DEVICE.

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(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.

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Article – Health – General

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15–148.
(A)

EXCEPT FOR A DRUG OR DEVICE FOR WHICH THE U.S. FOOD AND DRUG
ADMINISTRATION HAS ISSUED A BLACK BOX WARNING, THE PROGRAM AND THE
MARYLAND CHILDREN’S HEALTH PROGRAM MAY NOT APPLY A PRIOR
AUTHORIZATION REQUIREMENT FOR A CONTRACEPTIVE DRUG OR DEVICE THAT IS:
(1)

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(I)

AN INTRAUTERINE DEVICE; OR

(II)

AN IMPLANTABLE ROD;

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(2)

APPROVED BY THE U.S. FOOD AND DRUG ADMINISTRATION; AND

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(3)
PRESCRIBER.

OBTAINED UNDER A PRESCRIPTION WRITTEN BY AN AUTHORIZED

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(B) (1) EXCEPT AS PROVIDED IN PARAGRAPH (2) OF THIS SUBSECTION,
THE PROGRAM AND THE MARYLAND CHILDREN’S HEALTH PROGRAM SHALL

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PROVIDE COVERAGE FOR A SINGLE DISPENSING TO AN ENROLLEE OF A SUPPLY OF
PRESCRIPTION CONTRACEPTIVES FOR A 6–MONTH PERIOD.

(2)

PARAGRAPH (1) OF THIS SUBSECTION DOES NOT APPLY TO THE

FIRST 2–MONTH SUPPLY OF PRESCRIPTION CONTRACEPTIVES DISPENSED TO AN
ENROLLEE UNDER:

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(I)

THE INITIAL PRESCRIPTION FOR THE CONTRACEPTIVES; OR

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(II)

ANY SUBSEQUENT PRESCRIPTION FOR A CONTRACEPTIVE

THAT IS DIFFERENT THAN THE LAST CONTRACEPTIVE DISPENSED TO THE
ENROLLEE.

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SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all
policies, contracts, and health benefit plans subject to this Act that are issued, delivered,
or renewed in the State on or after January 1, 2018.

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SECTION 3. AND BE IT FURTHER ENACTED, That this Act shall take effect
January 1, 2018.

Approved:
________________________________________________________________________________
Governor.
________________________________________________________________________________
Speaker of the House of Delegates.
________________________________________________________________________________
President of the Senate.