What is an Upper Payment Limit?
An Upper Payment Limit (UPL) is a maximum amount that eligible entities will reimburse for certain prescription drugs. UPLs are set by the Board for certain drugs that may create an affordability challenge.
How Maryland Determines and Upper Payment Limit
The MD PDAB has a process (Cost Review Study process) to study certain drugs and determine if they may cause an affordability challenge to the state health care system or to patients. If the Board finds that a drug may cause an affordability challenge, then the Board can implement policies to make that drug more affordable. One of those tools is setting an upper payment limit (UPL). To set an UPL, the Board follows a comprehensive process with extensive public and stakeholder input, as outlined in COMAR 14.01.05.
Current Drugs in Maryland with an Upper Payment Limit
At this time, no drugs in Maryland have an active Upper Payment Limit. However, the Board has voted to apply UPLs to Jardiance and Ozempic. Maryland state and local governments (aka. Eligible Governmental Entities) will have the option to start implementing these UPLs starting on January 1, 2027, but they will be required to implement all active UPLs starting after January 1, 2028.
More information is available in the proposed regulations:
- COMAR 14.01.05
- COMAR 14.01.06.01
- COMAR 14.01.06.02