Status: Approved by the Governor (Chapter 692). Introduced Jan 27, 2025; approved May 20, 2025. Effective date / application: provisions take effect Jan 1, 2026 and apply to policies/contracts issued, delivered, or renewed on or after that date (fiscal note). The fiscal note also states the Act terminates July 1, 2029.
To prevent “accumulator” or similar programs from denying patients credit for third‑party financial assistance (copay coupons, manufacturer discounts, vouchers, patient assistance) when carriers calculate an enrollee’s contribution toward coinsurance, copayments, deductibles, or out‑of‑pocket (OOP) maximums for certain prescription drugs. The bill seeks to improve medication access and adherence by ensuring patient and third‑party payments reduce patients’ cost‑sharing obligations.
Scope: Applies to insurers, nonprofit health service plans, health maintenance organizations (HMOs), carriers, administrators, and pharmacy benefits managers (PBMs) that provide coverage in Maryland. Does not apply to health benefit plans subject to ERISA (self‑funded employer plans).
Counting assistance toward cost‑sharing: When calculating an insured’s/enrollee’s contribution to coinsurance, copayment, deductible, or OOP maximum, carriers/PBMs/administrators must include any discount, financial assistance payment, product voucher, or other out‑of‑pocket expense paid by or on behalf of the enrollee for a prescription drug that:
- Is covered under the enrollee’s benefit plan; and
- Either (a) has no AB‑rated generic equivalent or preferred interchangeable biosimilar, or (b) is a brand drug for which coverage was obtained via prior authorization, step therapy exception, or appeal.
High‑deductible health plans (HSA‑eligible HDHPs): The requirement does not apply to the HDHP deductible until the enrollee has satisfied the minimum deductible required under federal law; for preventive services, the rule applies regardless.
Third‑party notifications and limitations:
- A person who provides financial assistance that is used in the cost‑sharing calculation must notify the enrollee within 7 days after acceptance of the assistance of (1) the maximum dollar amount of the assistance and (2) the assistance’s expiration date.
- Third parties may not condition assistance on the enrollee taking certain actions (as specified in the law).
Carrier conduct restrictions: Carriers, administrators, and PBMs may not directly or indirectly set, alter, implement, or condition benefit design or plan terms based on information about the availability or amount of financial or product assistance for a prescription drug. This prohibition does not prevent carriers from using rebates in benefit design.
Enforcement: Violations may be treated as violations of the Maryland Consumer Protection Act (MCPA); the Insurance Commissioner may adopt implementing regulations.
