Relating to continuity of care and nonmedical switching by health carriers, health benefit plans, and utilization review organizations, and including applicability provisions

This bill relates to the continuity of care for a covered person and nonmedical switching by health carriers, health benefit plans, and utilization review organizations. The bill defines “nonmedical switching” as a health benefit plan’s restrictive changes to the health benefit plan’s formulary after the current plan year has begun or during the open enrollment period for the upcoming plan year, causing a covered person who is medically stable on the covered person’s current prescribed drug as determined by the prescribing health care professional, to switch to a less costly alternate prescription drug. “Health benefit plan”, “health carrier”, and “utilization review organization” are also defined in the bill. The bill provides that during a covered person’s eligibility under a health benefit plan, inclusive of any open enrollment period, a health plan carrier, health benefit plan, or utilization review organization shall not limit or exclude coverage of a prescription drug for the covered person if the covered person is medically stable on the drug as determined by the prescribing health care professional, the drug was previously approved by the health carrier for coverage for the person, and the covered person’s prescribing health care professional has prescribed the drug for the person’s medical condition within the previous six months. The bill includes, as prohibited limitations or exclusions, reducing the maximum coverage of prescription drug benefits, increasing cost sharing for a covered drug, moving a drug to a more restrictive tier, and removing a drug from a formulary. A prescription drug may, however, be removed from a formulary if the United States food and drug administration issues a statement regarding the clinical safety of the drug, or the manufacturer of the drug notifies the United States food and drug administration of a manufacturing discontinuance or potential discontinuance of the drug as required by section 506c of the Federal Food, Drug, and Cosmetic Act. The bill provides that a drug product with the same generic name and demonstrated bioavailability, or an interchangeable biological product, is considered equivalent to the prescription drug prescribed by the covered person’s health care professional. The bill requires a covered person and prescribing health care professional to have access to a process to request a coverage exemption determination. The bill defines “coverage exemption determination” as a determination made by a health carrier, health benefit plan, or utilization review organization whether to cover a prescription drug that is otherwise excluded from coverage. A coverage exemption determination request must be approved or denied by the health carrier, health benefit plan, or utilization review organization within five calendar days, or within hours if exigent circumstances exist. If a determination is not received within the applicable time period the coverage exemption is deemed granted. The bill requires a coverage exemption to be expeditiously granted for a health benefit plan that is discontinued for the next plan year if a covered person enrolls in a comparable plan offered by the same health carrier, and in comparison to the discontinued health benefit plan, the new health benefit plan limits or reduces the maximum coverage for a prescription drug, increases cost sharing for the prescription drug, moves the prescription drug to a more restrictive tier, or excludes the prescription drug from the formulary. If a coverage exemption is granted, the bill requires an authorization of coverage that is no more restrictive than that offered in the discontinued health benefit plan, or than that offered prior to implementation of restrictive changes to the health benefit plan’s formulary after the current plan year began. If a determination is made to deny a request for a coverage exemption, the reason for denial and the procedure to appeal the denial must be provided to the requestor. Any determination to deny a coverage exemption may be appealed to the health carrier, health benefit plan, or utilization review organization. A determination to uphold or reverse denial of a coverage exemption must be made within five calendar days of receipt of an appeal, or within hours if exigent circumstances exist. If a determination is not made within the applicable time period, the denial is deemed reversed and the coverage exemption is deemed approved. If a determination to deny a coverage exemption is upheld on appeal, the reason for upholding the denial and the procedure to request external review of the denial pursuant to Code chapter 514J must be provided to the individual who filed the appeal. Any denial of a request for a coverage exemption that is upheld on appeal is considered a final adverse determination for purposes of Code chapter 514J and is eligible for a request for external review by a covered person or the covered person’s authorized representative pursuant to Code chapter 514J. The bill shall not be construed to prevent a health care professional from prescribing another drug covered by the health carrier that the health care professional deems medically necessary for the covered person. The bill shall not be construed to prevent a health carrier from adding a drug to its formulary, or from removing a drug from its formulary if the drug manufacturer removes the drug for sale in the United States. The bill allows the commissioner to take any necessary enforcement action under the commissioner’s authority to enforce compliance with the bill. The bill is applicable to health benefit plans that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2023.