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EXPLANATION: CAPITALS INDICATE MATTER ADDED TO EXISTING LAW.
[Brackets] indicate matter deleted from existing law.
*hb1461*
HOUSE BILL 1461
J5 6lr2969
By: Delegates Taveras, Lehman, and Williams
Introduced and read first time: February 13, 2026
Assigned to: Health
A BILL ENTITLED
AN ACT concerning 1
Health Insurance – Coverage for Specialty Drugs – Rheumatologic Conditions 2
FOR the purpose of altering the circumstances under which certain insurers, nonprofit 3
health service plans, and health maintenance organizations are prohibited from 4
excluding coverage for certain specialty drugs for the treatment of rheumatologic 5
conditions; and generally relating to health insurance coverage for specialty drugs. 6
BY repealing and reenacting, with amendments, 7
Article – Insurance 8
Section 15–847.2 9
Annotated Code of Maryland 10
(2017 Replacement Volume and 2025 Supplement) 11
Preamble 12
WHEREAS, Specialty drugs are increasingly used to treat complex conditions such 13
as autoimmune diseases and rheumatologic disorders; and 14
WHEREAS, Many patients rely on their physician’s office or clinic to timely dispense 15
and administer specialty medications, particularly when these drugs require complex 16
dosing, clinical monitoring, or coordination with infusion therapies; and 17
WHEREAS, Payers and pharm acy benefit managers (PBMs) have increasingly 18
adopted policies that steer patients to designated specialty pharmacies often owned by the 19
payer or PBM; and 20
WHEREAS, Pharmacy steering practices can lead to treatment delays, shipment 21
errors, and interruptions in care; and 22
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WHEREAS, Providers dispensing specialty drugs within their clinical practice 1
settings must comply with rigorous State regulations, maintain extensive clinical 2
oversight, and ensure adherence, safety monitoring, and coordinated care; and 3
WHEREAS, Steering policies result in clinical providers being underpaid for 4
dispensing specialty drugs while allowing higher payments to designated specialty 5
pharmacies, creating financial disincentives that undermine patient access to office–based 6
care; and 7
WHEREAS, Ensuring adequate reimbursement for specialty drugs dispensed or 8
administered by office –based providers promotes competition and fairness across 9
dispensing channels; and 10
WHEREAS, It is the intent of the Maryland General Assembly to ensure that 11
insurers, nonprofit health service plans, and health maintenance organizations do not 12
exclude coverage for clinically appropriate specialty drugs when administered or dispensed 13
by qualified in–network providers who meet all State regulatory requirements; and 14
WHEREAS, Protecting patient choice and preserving clinically integrated care 15
models are essential to preventing disruptions in treatment for individuals with complex 16
and chronic conditions; now, therefore, 17
SECTION 1. BE IT ENACTED BY THE GENER AL ASSEMBLY OF MARYLAND, 18
That the Laws of Maryland read as follows: 19
Article – Insurance 20
15–847.2. 21
(a) In this section, “specialty drug” has the meaning stated in § 15 –847 of this 22
subtitle. 23
(b) (1) This section applies to: 24
(i) insurers and nonprofit health service plans that provide coverage 25
for prescription drugs under individual, group, or blanket health insurance policies or 26
contracts that are issued or delivered in the State; and 27
(ii) health maintenance organizations that provide cov erage for 28
prescription drugs under individual or group contracts that are issued or delivered in the 29
State. 30
(2) An insurer, a nonprofit health service plan, or a health maintenance 31
organization that provides coverage for prescription drugs through a pha rmacy benefits 32
manager is subject to the requirements of this section. 33
HOUSE BILL 1461 3
(c) An entity subject to this section may not exclude coverage for a covered 1
specialty drug administered or dispensed by a provider under § 12 –102 of the Health 2
Occupations Article if the entity determines that: 3
(1) (I) the provider that administers or dispenses the covered specialty 4
drug: 5
[(i)] 1. is an in –network provider of covered oncology services; 6
and 7
[(ii)] 2. complies with State regulations for the administering and 8
dispensing of specialty drugs; and 9
[(2)] (II) the covered specialty drug is: 10
[(i)] 1. auto–injected or an oral targeted immune modulator; or 11
[(ii)] 2. an oral medication that: 12
[1.] A. requires complex dosing based on clinical 13
presentation; or 14
[2.] B. is used concomitantly with other infusion or 15
radiation therapies; OR 16
(2) (I) FOR A SPECIALTY DRUG FOR THE TREATMENT OF 17
RHEUMATOLOGIC CONDITIONS, THE PROVIDER THAT AD MINISTERS OR DISPENSES 18
THE COVERED SPECIALTY DRUG: 19
1. IS AN IN–NETWORK PROVIDER OF COVERED 20
RHEUMATOLOGY SERVICES; AND 21
2. COMPLIES WITH THE STATE REGULATIONS FOR THE 22
ADMINISTERING AND DISPENSING OF SPECIALTY DRUGS; AND 23
(II) THE COVERED SPECIALTY DRUG IS: 24
1. AUTO–INJECTED OR AN ORAL TARGETED IMMUNE 25
MODULATOR; OR 26
2. AN ORAL MEDICATION THAT: 27
A. REQUIRES COMPLEX DOS ING BASED ON CLINICA L 28
PRESENTATION; OR 29
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B. IS USED CONCOMITANTL Y WITH OTHER INFUSIO N 1
THERAPIES. 2
(d) (1) Subject to subsection (f) of this section, the reimbursement rate for 3
specialty drugs covered under this section shall be: 4
(i) agreed to by the covered, in –network provider and the entity 5
subject to this section; and 6
(ii) billed at a nonhospital level of care or place of service. 7
(2) Unless otherwise agreed to by the covered, in–network provider and the 8
entity subject to this section, the reimbursement rate for specialty drugs covered under this 9
section may not exceed the rate applicable to a designated specialty pharmacy for 10
dispensing the covered specialty drugs. 11
(e) This section does not prohibit an entity subject to this section from refusing to 12
authorize or approve or from denying coverage for a covered specialty drug administered or 13
dispensed by a provider if administering or dispensing the drug fails to satisfy medical 14
necessity criteria. 15
(f) This section may not be construed to supersede the authority of the Health 16
Services Cost Review Commission to set rates for specialty drugs administered to patients 17
in a setting regulated by the Health Services Cost Review Commission. 18
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall apply to all 19
policies, contracts, and health benefit plans issued, delivered, or renewed in the State on or 20
after January 1, 2027. 21
SECTION 3. AND BE IT FURTHER ENACTED, That this A ct shall take effect 22
January 1, 2027. 23