No. SB 1166
Filed under Insurance.
Insurer Disclosures on Prescription Drug Coverage; Requiring individual and group health insurers to provide notice of prescription drug formulary changes within a certain timeframe to current and prospective insureds and the insureds’ treating physicians; requiring insurers to maintain a record of formulary changes; defining the term “cost-sharing requirement”; providing an exception to requirements relating to changes in a health maintenance organization’s group contract, etc.
Plain English Summary
AI-GENERATEDInsurers and HMOs must notify patients and their doctors 60 days before changing a drug's formulary status. If a doctor certifies the drug is medically necessary, coverage continues unchanged through the rest of the policy year.
Once that certification is accepted, the insurer cannot raise the patient's costs, move the drug to a worse tier, deny previously approved coverage, or add new prior-authorization or step-therapy requirements for the rest of the year.
Manufacturer copay cards and coupons must count toward a patient's deductible, but only for drugs with no generic version, or when the patient got separate authorization to use a brand-name drug despite a generic existing.
Insurers must track formulary changes and unclaimed manufacturer payments and report both to state regulators every year, who compile the data into a public report for the Governor and Legislature.
AIIndividual, group, and HMO insurers must notify current and prospective enrollees and their treating physicians at least 60 days before any prescription drug formulary change takes effect, through the insurer's website, electronic notice, and first-class mail.
AIOnce a treating physician's certification of medical necessity is accepted, the insurer may not increase out-of-pocket costs for the drug, move it to a more restrictive tier, deny previously approved coverage, or otherwise limit it, including through a new prior-authorization or step-therapy requirement, for the rest of the policy year.
AIInsurers and pharmacy benefit managers must apply manufacturer coupons, copay cards, and other third-party payments toward a patient's cost-sharing requirement when the prescribed drug has no generic equivalent, or when the patient obtained authorization to use it despite a generic existing.
AIContracts between insurers and pharmacy benefit managers must require the PBM to apply qualifying third-party payments toward the insured's cost-sharing requirement, and to disclose that duty to every insured directly.
AIHealth insurers and HMOs must track formulary changes and submit annual reports to the Office of Insurance Regulation by March 1, listing removed drugs, tier changes, and added costs to insureds; the office must then compile and publish this data and send it to the Governor and Legislature by May 1.
AIFor HMO group contracts, the general rule letting a 45-day notice suffice to cut or downgrade benefits no longer covers prescription drug formulary changes; those are now governed exclusively by the new 60-day notice and certification-lock requirements.