2015 -- H 5599

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LC001450

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2015

____________

A N   A C T

RELATING TO INSURANCE -- DRUG COVERAGE

     

     Introduced By: Representatives Corvese, Azzinaro, and Winfield

     Date Introduced: February 25, 2015

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

1

     SECTION 1. Section 27-18-50 of the General Laws in Chapter 27-18 entitled "Accident

2

and Sickness Insurance Policies" is hereby amended to read as follows:

3

     27-18-50. Drug coverage. -- (a) Any accident and sickness insurer that utilizes a

4

formulary of medications for which coverage is provided under an individual or group plan

5

master contract shall require any physician or other person authorized by the department of health

6

to prescribe medication to prescribe from the formulary. A physician or other person authorized

7

by the department of health to prescribe medication shall be allowed to prescribe medications

8

previously on, or not on, the accident and sickness insurer's formulary if he or she believes that

9

the prescription of the non-formulary medication is medically necessary. An accident and

10

sickness insurer shall be required to provide coverage for a non-formulary medication only when

11

the non-formulary medication meets the accident and sickness insurer's medical exception criteria

12

for the coverage of that medication.

13

      (b) An accident and sickness insurer's medical exception criteria for the coverage of non-

14

formulary medications shall be developed in accordance with § 23-17.13-3(c)(3).

15

      (c) Any subscriber who is aggrieved by a denial of benefits to be provided under this

16

section may appeal the denial in accordance with the rules and regulations promulgated by the

17

department of health pursuant to chapter 17.12 of title 23.

18

     (d) Prior to removing a prescription drug from its plan's formulary or making any change

19

in the preferred or tiered cost-sharing status of a covered prescription drug, an accident and

 

1

sickness insurer must provide at least sixty (60) days' notice to authorized prescribers, network

2

pharmacies, and pharmacists prior to the date such change becomes effective, and must either:

3

     (1) Provide direct written notice to affected subscribers at least sixty (60) days prior to

4

the date the change becomes effective; or

5

     (2) At the time an affected subscriber requests a refill of the prescription drug, provide

6

such subscriber with a sixty (60) day supply of the prescription drug under the same terms as

7

previously allowed, and written notice of the formulary change:

8

     (i) The written notice must contain the following information:

9

     (A) The name of the affected prescription drug;

10

     (B) Whether the plan is removing the prescription drug from the formulary, or changing

11

its preferred or tiered cost-sharing status;

12

     (C) The reason why the plan is removing such prescription drug from the formulary, or

13

changing its preferred or tiered cost-sharing status;

14

     (D) Alternative drugs in the same therapeutic category or class or cost-sharing tier and

15

expected cost-sharing for those drugs; and

16

     (E) The means by which subscribers may obtain a coverage determination under or

17

exception;

18

     (ii) An accident and sickness insurer may immediately remove from their plan

19

formularies covered prescription drugs deemed unsafe by the Food and Drug Administration or

20

removed from the market by their manufacturer without meeting the requirements of this section.

21

Nonprofit dental service corporations must provide retrospective notice of any such formulary

22

changes to affected subscribers, authorized prescribers, network pharmacies, and pharmacists

23

consistent with the requirements of this section.

24

      (d)(e) This section shall not apply to insurance coverage providing benefits for: (1)

25

hospital confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5)

26

Medicare supplement; (6) limited benefit health; (7) specified disease indemnity; (8) sickness or

27

bodily injury or death by accident or both; or (9) other limited benefit policies.

28

     SECTION 2. Section 27-19-42 of the General Laws in Chapter 27-19 entitled "Nonprofit

29

Hospital Service Corporations" is hereby amended to read as follows:

30

     27-19-42. Drug coverage. -- (a) Any nonprofit hospital service corporation that utilizes a

31

formulary of medications for which coverage is provided under an individual or group plan

32

master contract shall require any physician or other person authorized by the department of health

33

to prescribe medication to prescribe from the formulary. A physician or other person authorized

34

by the department of health to prescribe medication shall be allowed to prescribe medications

 

LC001450 - Page 2 of 8

1

previously on, or not on, the nonprofit hospital service corporation's formulary if he or she

2

believes that the prescription of the non-formulary medication is medically necessary. A

3

nonprofit hospital service corporation shall be required to provide coverage for a non-formulary

4

medication only when the non-formulary medication meets the nonprofit hospital service

5

corporation's medical exception criteria for the coverage of that medication.

6

      (b) A nonprofit hospital service corporation's medical exception criteria for the coverage

7

of non-formulary medications shall be developed in accordance with § 23-17.13-3(c)(3).

8

      (c) Any subscriber who is aggrieved by a denial of benefits to be provided under this

9

section may appeal the denial in accordance with the rules and regulations promulgated by the

10

department of health pursuant to chapter 17.12 of title 23.

11

     (d) Prior to removing a prescription drug from its plan's formulary or making any change

12

in the preferred or tiered cost-sharing status of a covered prescription drug, an accident and

13

sickness insurer must provide at least sixty (60) days' notice to authorized prescribers, network

14

pharmacies, and pharmacists prior to the date such change becomes effective, and must either:

15

     (1) Provide direct written notice to affected subscribers at least sixty (60) days prior to

16

the date the change becomes effective; or

17

     (2) At the time an affected subscriber requests a refill of the prescription drug, provide

18

such subscriber with a sixty (60) day supply of the prescription drug under the same terms as

19

previously allowed, and written notice of the formulary change.

20

     (i) The written notice must contain the following information:

21

     (A) The name of the affected prescription drug;

22

     (B) Whether the plan is removing the prescription drug from the formulary, or changing

23

its preferred or tiered cost-sharing status;

24

     (C) The reason why the plan is removing such prescription drug from the formulary, or

25

changing its preferred or tiered cost-sharing status;

26

     (D) Alternative drugs in the same therapeutic category or class or cost-sharing tier and

27

expected cost-sharing for those drugs; and

28

     (E) The means by which subscribers may obtain a coverage determination under or

29

exception;

30

     (ii) An accident and sickness insurer may immediately remove from their plan

31

formularies covered prescription drugs deemed unsafe by the Food and Drug Administration or

32

removed from the market by their manufacturer without meeting the requirements of this section.

33

Nonprofit dental service corporations must provide retrospective notice of any such formulary

34

changes to affected subscribers, authorized prescribers, network pharmacies, and pharmacists

 

LC001450 - Page 3 of 8

1

consistent with the requirements of this section.

2

     SECTION 3. Section 27-20-37 of the General Laws in Chapter 27-20 entitled "Nonprofit

3

Medical Service Corporations" is hereby amended to read as follows:

4

     27-20-37. Drug coverage. -- (a) Any nonprofit medical service corporation that utilizes a

5

formulary of medications for which coverage is provided under an individual or group plan

6

master contract shall require any physician or other person authorized by the department of health

7

to prescribe medication to prescribe from the formulary. A physician or other person authorized

8

by the department of health to prescribe medication shall be allowed to prescribe medications

9

previously on, or not on, the nonprofit medical service corporation's formulary if he or she

10

believes that the prescription of the non-formulary medication is medically necessary. A

11

nonprofit hospital service corporation shall be required to provide coverage for a non-formulary

12

medication only when the non-formulary medication meets the nonprofit medical service

13

corporation's medical exception criteria for the coverage of that medication.

14

      (b) A nonprofit medical service corporation's medical exception criteria for the coverage

15

of non-formulary medications shall be developed in accordance with § 23-17.13-3(c)(3).

16

      (c) Any subscriber who is aggrieved by a denial of benefits to be provided under this

17

section may appeal the denial in accordance with the rules and regulations promulgated by the

18

department of health pursuant to chapter 17.12 of title 23.

19

     (d) Prior to removing a prescription drug from its plan's formulary or making any change

20

in the preferred or tiered cost-sharing status of a covered prescription drug, an accident and

21

sickness insurer must provide at least sixty (60) days' notice to authorized prescribers, network

22

pharmacies, and pharmacists prior to the date such change becomes effective, and must either:

23

     (1) Provide direct written notice to affected subscribers at least sixty (60) days prior to

24

the date the change becomes effective; or

25

     (2) At the time an affected subscriber requests a refill of the prescription drug, provide

26

such subscriber with a sixty (60) day supply of the prescription drug under the same terms as

27

previously allowed, and written notice of the formulary change:

28

     (i) The written notice must contain the following information:

29

     (A) The name of the affected prescription drug;

30

     (B) Whether the plan is removing the prescription drug from the formulary, or changing

31

its preferred or tiered cost-sharing status;

32

     (C) The reason why the plan is removing such prescription drug from the formulary, or

33

changing its preferred or tiered cost-sharing status;

34

     (D) Alternative drugs in the same therapeutic category or class or cost-sharing tier and

 

LC001450 - Page 4 of 8

1

expected cost-sharing for those drugs; and

2

     (E) The means by which subscribers may obtain a coverage determination under or

3

exception;

4

     (ii) An accident and sickness insurer may immediately remove from their plan

5

formularies covered prescription drugs deemed unsafe by the Food and Drug Administration or

6

removed from the market by their manufacturer without meeting the requirements of this section.

7

Nonprofit dental service corporations must provide retrospective notice of any such formulary

8

changes to affected subscribers, authorized prescribers, network pharmacies, and pharmacists

9

consistent with the requirements of this section.

10

     SECTION 4. Section 27-20.1-15 of the General Laws in Chapter 27-20.1 entitled

11

"Nonprofit Dental Service Corporations" is hereby amended to read as follows:

12

     27-20.1-15. Drug coverage. -- (a) Any nonprofit dental service corporation that utilizes a

13

formulary of medications for which coverage is provided under an individual or group plan

14

master contract shall require any physician or other person authorized by the department of health

15

to prescribe medication to prescribe from the formulary. A physician or other person authorized

16

by the department of health to prescribe medication shall be allowed to prescribe medications

17

previously on, or not on, the nonprofit dental service corporation's formulary if he or she believes

18

that the prescription of the non-formulary medication is medically necessary. A nonprofit dental

19

service corporation shall be required to provide coverage for a non-formulary medication only

20

when the non-formulary medication meets the nonprofit dental service corporation's medical

21

exception criteria for the coverage of that medication.

22

      (b) A nonprofit dental service corporation's medical exception criteria for the coverage

23

of non-formulary medications shall be developed in accordance with § 23-17.13-3(c)(3).

24

      (c) Any subscriber who is aggrieved by a denial of benefits to be provided under this

25

section may appeal the denial in accordance with the rules and regulations promulgated by the

26

department of health pursuant to chapter 17.12 of title 23.

27

     (d) Prior to removing a prescription drug from its plan's formulary or making any change

28

in the preferred or tiered cost-sharing status of a covered prescription drug, an accident and

29

sickness insurer must provide at least sixty (60) days' notice to authorized prescribers, network

30

pharmacies, and pharmacists prior to the date such change becomes effective, and must either:

31

     (1) Provide direct written notice to affected subscribers at least sixty (60) days prior to

32

the date the change becomes effective; or

33

     (2) At the time an affected subscriber requests a refill of the prescription drug, provide

34

such subscriber with a sixty (60) day supply of the prescription drug under the same terms as

 

LC001450 - Page 5 of 8

1

previously allowed, and written notice of the formulary change:

2

     (i) The written notice must contain the following information:

3

     (A) The name of the affected prescription drug;

4

     (B) Whether the plan is removing the prescription drug from the formulary, or changing

5

its preferred or tiered cost-sharing status;

6

     (C) The reason why the plan is removing such prescription drug from the formulary, or

7

changing its preferred or tiered cost-sharing status;

8

     (D) Alternative drugs in the same therapeutic category or class or cost-sharing tier and

9

expected cost-sharing for those drugs; and

10

     (E) The means by which subscribers may obtain a coverage determination under or

11

exception;

12

     (ii) An accident and sickness insurer may immediately remove from their plan

13

formularies covered prescription drugs deemed unsafe by the Food and Drug Administration or

14

removed from the market by their manufacturer without meeting the requirements of this section.

15

Nonprofit dental service corporations must provide retrospective notice of any such formulary

16

changes to affected subscribers, authorized prescribers, network pharmacies, and pharmacists

17

consistent with the requirements of this section.

18

     SECTION 5. Section 27-41-51 of the General Laws in Chapter 27-41 entitled "Health

19

Maintenance Organizations" is hereby amended to read as follows:

20

     27-41-51. Drug coverage. -- (a) Any health maintenance organization that utilizes a

21

formulary of medications for which coverage is provided under an individual or group plan

22

master contract shall require any physician or other person authorized by the department of health

23

to prescribe medication to prescribe from the formulary. A physician or other person authorized

24

by the department of health to prescribe medication shall be allowed to prescribe medications

25

previously on, or not on, the health maintenance organization's formulary if he or she believes

26

that the prescription of non-formulary medication is medically necessary. A health maintenance

27

organization shall be required to provide coverage for a non-formulary medication only when the

28

non-formulary medication meets the health maintenance organization's medical exception criteria

29

for the coverage of that medication.

30

      (b) A health maintenance organization's medical exception criteria for the coverage of

31

non-formulary medications shall be developed in accordance with § 23-17.13-3(c)(3).

32

      (c) Any subscriber who is aggrieved by a denial of benefits to be provided under this

33

section may appeal the denial in accordance with the rules and regulations promulgated by the

34

department of health pursuant to chapter 17.12 of title 23.

 

LC001450 - Page 6 of 8

1

     (d) Prior to removing a prescription drug from its plan's formulary or making any change

2

in the preferred or tiered cost-sharing status of a covered prescription drug, an accident and

3

sickness insurer must provide at least sixty (60) days' notice to authorized prescribers, network

4

pharmacies, and pharmacists prior to the date such change becomes effective, and must either:

5

     (1) Provide direct written notice to affected subscribers at least sixty (60) days prior to

6

the date the change becomes effective; or

7

     (2) At the time an affected subscriber requests a refill of the prescription drug, provide

8

such subscriber with a sixty (60) day supply of the prescription drug under the same terms as

9

previously allowed, and written notice of the formulary change:

10

     (i) The written notice must contain the following information:

11

     (A) The name of the affected prescription drug;

12

     (B) Whether the plan is removing the prescription drug from the formulary, or changing

13

its preferred or tiered cost-sharing status;

14

     (C) The reason why the plan is removing such prescription drug from the formulary, or

15

changing its preferred or tiered cost-sharing status;

16

     (D) Alternative drugs in the same therapeutic category or class or cost-sharing tier and

17

expected cost-sharing for those drugs; and

18

     (E) The means by which subscribers may obtain a coverage determination under or

19

exception;

20

     (ii) An accident and sickness insurer may immediately remove from their plan

21

formularies covered prescription drugs deemed unsafe by the Food and Drug Administration or

22

removed from the market by their manufacturer without meeting the requirements of this section.

23

Nonprofit dental service corporations must provide retrospective notice of any such formulary

24

changes to affected subscribers, authorized prescribers, network pharmacies, and pharmacists

25

consistent with the requirements of this section.

26

     SECTION 6. This act shall take effect on January 1, 2016.

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LC001450

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- DRUG COVERAGE

***

1

     This act would require any health care insurance company to notify authorized

2

prescribers, network pharmacies, and pharmacists at least sixty (60) days' prior to removing a

3

prescription drug from its plan's formulary, or making any change in the preferred or tiered cost-

4

sharing status of a covered prescription drug. Any health care insurer must provide direct written

5

notice to affected subscribers at least sixty (60) days prior to the date the change becomes

6

effective; or at the time an affected subscriber requests a refill of the prescription drug, provide

7

such subscriber with a sixty (60) day supply of the prescription drug under the same terms as

8

previously allowed, and written notice of the formulary change.

9

     This act would take effect on January 1, 2016.

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LC001450

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LC001450 - Page 8 of 8