Section 15-854 - [Effective 1/1/2025] Prior authorization for prescription drug(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.(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.(c)(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 lesser of 90 days or the length of the course of treatment.(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.(d)(1) An entity subject to this section shall honor a prior authorization issued by the entity for a prescription drug and may not require a health care provider to submit a request for another prior authorization for the 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) Except as provided in § 15-851 of this subtitle, an entity may require a prior authorization for a change in dosage for an opioid under this subsection.(e)(1) 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 60 days before the implementation of a new prior authorization requirement:(i) in writing to any insured who is prescribed the prescription drug; and(ii) either in writing or electronically to all contracted health care providers.(2) The notice required under paragraph (1) of this subsection shall indicate that the insured may remain on the prescription drug at the time of reauthorization in accordance with subsection (g) of this section.(f)(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.(g)(1) An entity subject to this section may not issue an adverse decision on a reauthorization for the same prescription drug or request additional documentation from the prescriber for the reauthorization request if:
(i) the prescription drug is: 1. an immune globulin (human) as defined in 21 C.F.R. § 640.100; or2. used for the treatment of a mental disorder listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association;(ii) the entity previously approved a prior authorization for the prescription drug for the insured;(iii) the insured has been treated with the prescription drug without interruption since the initial approval of the prior authorization; and(iv) the prescriber attests that, based on the prescriber's professional judgment, the prescription drug continues to be necessary to effectively treat the insured's condition.(2) If the prescription drug that is being requested has been removed from the formulary or has been moved to a higher deductible, copayment, or coinsurance tier, the entity shall provide the insured and insured's health care provider the information required under § 15-831 of this subtitle.Amended by 2024 Md. Laws, Ch. 848,Sec. 1, eff. 1/1/2025.Amended by 2024 Md. Laws, Ch. 847,Sec. 1, eff. 1/1/2025.Amended by 2023 Md. Laws, Ch. 365, Sec. 1, eff. 1/1/2024.Amended by 2023 Md. Laws, Ch. 364, Sec. 1, eff. 1/1/2024.Added by 2019 Md. Laws, Ch. 549, Sec. 1, eff. 1/1/2020.This section is set out more than once due to postponed, multiple, or conflicting amendments.