Relates to prescription drug formulary changes during a contract year

1 Co-sponsor

• Terrence P. Murphy

Title of bill

An act to amend the insurance law, in relation to prescription drug formulary changes during a contract year

Purpose

To clarify that health insurance consumers covered by plans that are required to offer essential health benefits under the affordable care act are protected from adverse effects of mid-year formulary changes.

Summary of provisions

Section 1 creates a new subsection 4909-a of the Insurance Law to state that a health care plan which provides essential health benefits under the federal affordable care act may not remove a prescription drug from a formulary during the enrollment year. If the plan's drug formulary has two or more tiers of drug benefits with different deductibles, copayments or coinsurance, the plan may not move a drug to a tier with higher patient cost sharing during the enrollment year. The plan may also not add new or additional formulary restrictions during the enrollment year. A health care plan may move a prescription drug to a tier with a larger copayment, coinsurance and different deductible if an AB-rated generic equivalent drug is added to the formulary at the same time.

Section 2 provides that this act would take effect on the 60th day after enactment, provided that effective immediately the superintendent of insurance may make regulations and take other actions necessary to implement the act.

Justification

The purpose of the bill is to ensure that enrollees who select a health exchange plan based on their individual prescription drug needs have assurance that the health plan will maintain continuity in coverage for those prescription drugs during the course of the enrollment year. Enrollees choose health exchange plans based on the formulary status of a necessary therapy. A change in prescription drug availability could result in serious medical problems for the enrollee. Also, these unexpected formulary changes can be extremely financially burdensome.

Legislative history

This is a new bill.

Fiscal implications

None.

Effective date

On the 60th day after enactment,provided that effective immediately the superintendent of insurance may make regulations and take other actions necessary to implement the act.