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Bill

HB 1243

Health Insurance - Coverage for Specialty Drugs

2025 Regular Session Introduced by Tiffany Alston and 22 co-sponsors

Maryland law now requires health insurers to cover specialty drugs with reduced prior authorization barriers and capped cost-sharing for complex disease treatments.

Approved by the Governor - Chapter 729
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Bill Summary · HB 1243

Legislative bill overview

HB 1243 requires Maryland health insurance plans to provide coverage for specialty drugs, which are typically high-cost medications used to treat complex conditions like cancer, autoimmune diseases, and rare disorders. The bill establishes standards for how insurers must handle prior authorization, formulary placement, and cost-sharing for these medications. It became law in May 2025 after passing both chambers and receiving gubernatorial approval.

Why is this important

Specialty drugs can cost thousands of dollars per month, making them inaccessible without insurance coverage. This bill directly affects patients with serious illnesses by limiting out-of-pocket costs and reducing insurer barriers to treatment. It also impacts insurance premiums, as these expensive medications increase overall healthcare costs that insurers pass along to consumers.

Potential points of contention

  • Premium increases: Mandating specialty drug coverage will likely increase insurance premiums for all policyholders, including those who don't use these medications
  • Prior authorization restrictions: Limiting insurers' ability to require prior authorization may reduce their cost control mechanisms, potentially driving up utilization and expenses
  • Formulary requirements: Forcing broader drug coverage could limit insurers' negotiating power with pharmaceutical companies and their ability to steer patients toward cost-effective alternatives
  • Definition scope: The bill's definition of "specialty drugs" may be ambiguous, creating disputes over which medications qualify for enhanced coverage
  • Insurance market impact: Stricter regulations could cause insurers to exit the Maryland market or raise rates significantly

Compiled from official sources — confirm details with the bill’s official record.

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