Arizona 2024 Regular Session

Arizona Senate Bill SB1164 Compare Versions

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1-Senate Engrossed pharmacy benefits; coverage; exemptions (now: pharmacy benefits; coverage) State of Arizona Senate Fifty-sixth Legislature Second Regular Session 2024 SENATE BILL 1164 An Act amending title 20, chapter 25, article 2, Arizona Revised Statutes, by adding section 20-3335; relating to pharmacy benefit managers. (TEXT OF BILL BEGINS ON NEXT PAGE)
1+REFERENCE TITLE: pharmacy benefits; coverage; exemptions State of Arizona Senate Fifty-sixth Legislature Second Regular Session 2024 SB 1164 Introduced by Senators Shamp: Burch An Act amending title 20, chapter 25, article 2, Arizona Revised Statutes, by adding section 20-3335; relating to pharmacy benefit managers. (TEXT OF BILL BEGINS ON NEXT PAGE)
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9-Senate Engrossed pharmacy benefits; coverage; exemptions (now: pharmacy benefits; coverage)
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1010 State of Arizona Senate Fifty-sixth Legislature Second Regular Session 2024
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5564 An Act
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5968 amending title 20, chapter 25, article 2, Arizona Revised Statutes, by adding section 20-3335; relating to pharmacy benefit managers.
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69- Be it enacted by the Legislature of the State of Arizona: Section 1. Title 20, chapter 25, article 2, Arizona Revised Statutes, is amended by adding section 20-3335, to read: START_STATUTE20-3335. Pharmacy benefit managers; prescribing; coverage exemption determination process; enforcement; applicability; definitions A. If a pharmacy benefit manager enters into an agreement with a health care insurer to provide pharmacy benefit management services to covered individuals, the pharmacy benefit manager, on behalf of the pharmacy benefit manager or a health care insurer: 1. May not limit or exclude coverage of a prescription drug for any covered individual who is on a specific prescription drug if both of the following apply: (a) the prescription drug was previously approved by the pharmacy benefit manager or health care insurer for coverage for the covered individual. (b) the covered individual continues to be an enrollee of the health care insurer that the pharmacy benefit manager has contracted with to provide pharmacy benefit management services. 2. If paragraph 1 of this subsection applies, shall continue coverage of a covered individual's specific prescription drug through the last day of the covered individual's plan year. B. For the purposes of subsection a of this section, a pharmacy benefit manager, on behalf of the pharmacy benefit manager or a health care insurer, may not do any of the following for a covered individual identified under subsection a of this section: 1. Limit or reduce the maximum coverage of prescription drug benefits. 2. Increase cost sharing for a covered prescription drug. 3. Move a prescription drug to a more restrictive formulary tier. 4. Remove a prescription drug from a formulary unless either of the following applies: (a) the united states food and drug administration revokes approval for or removes a prescription drug from the prescription drug market. (b) the prescription drug manufacturer notifies the united states food and drug administration of a manufacturing discontinuation or a potential discontinuation as required by section 506c of the federal food, drug, and cosmetic act. C. If a pharmacy benefit manager or health care insurer makes any formulary change during a plan year, the pharmacy benefit manager or health care insurer shall provide written notice of the formulary change for any prescription drug on the drug formulary to each impacted covered individual and the impacted covered individual's prescribing health care provider at least sixty days before the FORMULARY change during the plan year. The pharmacy benefit manager or health care insurer may only change a covered individual from the previously covered prescription drug if the covered individual's prescribing health care provider provides written authorization to the pharmacy benefit manager or health care insurer for the change in the prescription drug. D. A pharmacy benefit manager or health care insurer shall provide written notice of the removal from or an increase in cost sharing for any prescription drug on the drug formulary to each impacted covered individual and the impacted covered individual's prescribing health care provider at least sixty days before the end of the plan year, if the covered individual's prescribing health care provider did not previously approve a change in the prescription drug. the notice shall set forth the process by which the covered individual's health care provider may request a prescription drug coverage exemption for the continued use of the nonformulary prescription drug and the exemption process shall comply with subsection e of this section. E. A prescription drug coverage exemption determination process is available to covered individuals and the prescribing health care provider to ensure continuity of care after a covered individual's renewal in the following manner: 1. A health care insurer, pharmacy benefit manager or utilization review agent that is contracted to provide pharmacy benefit management services for the health care insurer shall provide a covered individual and prescribing health care provider with access to a clear and convenient process to request a coverage exemption determination. The health care insurer, pharmacy benefit manager or utilization review agent may use its existing medical exceptions process to satisfy this requirement if the medical exceptions process is consistent with the requirements prescribed in this section. 2. A health care insurer, pharmacy benefit manager or utilization review agent shall respond to a coverage exemption determination request within the timelines outlined in 45 Code of Federal regulations section 156.122. 3. A health care insurer, pharmacy benefit manager or utilization review agent shall approve a prescription drug coverage exemption for a covered individual who has been previously approved to receive the nonformulary prescription drug by the covered individual's current health care insurer or pharmacy benefit manager and the prescribing health care provider continues to prescribe the prescription drug for the covered individual's medical condition. 4. Denial of coverage for a health care insurer's or pharmacy benefit manager's denial of coverage for a nonformulary prescription drug shall be made in writing by a licensed pharmacist or medical director. The written denial shall contain an explanation of the denial that includes the medical or pharmacological reasons why the authorization was denied and a signature by the licensed pharmacist or medical director who made the decision to deny coverage. The corporation shall send a copy of the written denial to the covered individual's treating health care provider who requested the authorization. The corporation shall maintain copies of all written denials and shall make the copies available to the department for inspection during regular business hours. A covered individual or the covered individual's authorized representative may appeal any determination to deny a coverage exemption. The written notification shall include the process in which a covered individual may appeal the determination. 5. If the corporation authorizes a coverage exemption for a covered individual pursuant to this section, that authorization shall be in effect until the end of the covered individual's plan year. The approval of a coverage exemption shall be in writing and delivered to the covered individual and the covered individual's treating health care provider. F. This section does not: 1. Prevent a health care provider from prescribing another prescription drug covered by the carrier, the health care insurer or the pharmacy benefit manager, if the carrier, health care insurer or the pharmacy benefit manager is contracted to provide pharmacy benefit management services and the health care provider deems the prescription drug medically necessary for the covered individual. 2. Prevent a health care insurer or pharmacy benefit manager contracted to provide pharmacy benefit management services from: (a) adding a prescription drug to its formulary. (b) removing a prescription drug from its formulary if the drug manufacturer has removed the prescription drug for sale in the united states. (c) making any formulary changes for patients who are not on a previously approved prescription drug. g. If a health care insurer, pharmacy benefit manager or utilization review agent that is contracted to provide pharmacy benefit management services violates this section, the director may impose a civil penalty against that health care insurer, pharmacy benefit manager or utilization review agent. H. A policy that is issued or renewed by a disability insurer does not include a policy that provides limited benefit coverage as defined in section 20-1137. i. For the purposes of this section: 1. "coverage exemption" means that immediate coverage of a health care provider's selected prescription drug is granted. 2. "health care insurer" has the same meaning prescribed in section 20-2501. 3. "health care plan" means a policy, contract or evidence of coverage that a health care insurer issues to an insured, enrollee or subscriber. 4. "utilization review agent" has the same meaning prescribed in section 20-2530. END_STATUTE Sec. 2. Applicability This act applies to contracts entered into, amended, extended or renewed on or after December 31, 2024.
78+ Be it enacted by the Legislature of the State of Arizona: Section 1. Title 20, chapter 25, article 2, Arizona Revised Statutes, is amended by adding section 20-3335, to read: START_STATUTE20-3335. Pharmacy benefit managers; prescribing; coverage exemption determination process; enforcement; definitions A. If a pharmacy benefit manager enters into an agreement with a health care insurer to provide pharmacy benefit management services to covered individuals, the pharmacy benefit manager, on behalf of the pharmacy benefit manager or a health care insurer: 1. May not limit or exclude coverage of a prescription drug for any covered individual who is medically stable on a specific prescription drug as determined by the covered individual's prescribing health care professional, if both of the following apply: (a) The prescription drug was previously approved by the pharmacy benefit manager or health care insurer for coverage for the covered individual. (b) The covered individual continues to be an enrollee of the health care insurer that the pharmacy benefit manager has contracted with to provide pharmacy benefit management services. 2. Shall continue coverage of a covered individual's prescription drug as described in paragraph 1 of this subsection through the last day of the covered individual's eligibility under the covered individual's health benefit plan, including any open enrollment period. B. For the purposes of subsection A, paragraph 1 of this section, a pharmacy benefit manager, on behalf of the pharmacy benefit manager or a health care insurer, may not do any of the following: 1. Limit or reduce the maximum coverage of prescription drug benefits. 2. Increase cost sharing for a covered prescription drug. 3. Move a prescription drug to a more restrictive formulary tier. 4. Remove a prescription drug from a formulary unless either of the following applies: (a) The United States food and drug administration revokes approval for or removes a prescription drug from the prescription drug market. (b) The prescription drug manufacturer notifies the United States food and drug administration of a manufacturing discontinuation or a potential discontinuation, as required by section 506c of the federal food, drug, and cosmetic act. C. A prescription coverage exemption determination process is available to covered individuals and the prescribing health care professional to ensure continuity of care as follows: 1. A health care insurer, pharmacy benefit manager or utilization review agent that is contracted to provide pharmacy benefit management services for the health care insurer shall provide a covered individual and prescribing health care professional with access to a clear and convenient process to request a coverage exemption determination. A health care insurer, pharmacy benefit manager or utilization review agent that is contracted to provide pharmacy benefit management services for the health care insurer may use its existing medical exceptions process to satisfy this requirement if the medical exceptions process is consistent with the requirements prescribed in this section. 2. A health care insurer, pharmacy benefit manager or utilization review agent shall respond to a coverage exemption determination request within seventy-two hours after receipt. In cases where exigent circumstances exist, the health care insurer, pharmacy benefit manager or utilization review agent shall respond within twenty-four hours after receipt if provided with sufficient justification and any supporting clinical documentation. If a response by the health care insurer, pharmacy benefit manager or utilization review agent is not received within the applicable time frame, the coverage exemption is automatically granted. 3. A coverage exemption shall be expeditiously granted for a discontinued health benefit plan, including a health benefit plan from an individual's prior plan year, if a covered individual enrolls in a comparable plan offered by the same group health plan offering group or individual health insurance coverage, and all of the following conditions apply: (a) The covered individual is medically stable on a prescription drug as determined by the covered individual's prescribing health care professional. (b) The prescribing health care professional continues to prescribe the drug for the covered individual for the covered individual's medical condition. (c) In comparison to the discontinued health benefit plan, the new health benefit plan does any of the following: (i) Limits or reduces the maximum coverage of prescription drug benefits. (ii) Increases cost sharing for the prescription drug. (iii) Moves the prescription drug to a more restrictive tier if the carrier, insurer or pharmacy benefit manager uses a formulary with tiers. (iv) Excludes the prescription drug from the carrier's, insurer's or pharmacy benefit manager's formulary. 4. A coverage exemption shall be expeditiously granted for a covered individual without a discontinued health benefit plan if the covered individual has previously received the prescription drug by any means, including participation in a clinical trial, third-party patient assistance or other financial support programs, and all of the following conditions apply: (a) The covered individual is medically stable on a prescription drug as determined by the covered individual's prescribing health care professional. (b) The prescribing health care professional continues to prescribe the drug for the covered individual for the covered individual's medical condition. (c) The prescription drug was not provided as a pharmaceutical sample. 5. If a request for a coverage exemption is denied, the health care insurer, pharmacy benefit manager or utilization review agent contracted to provide pharmacy benefit management services shall provide the covered individual or the covered individual's prescribing health care professional with the reasons for the denial and information regarding the procedure to appeal the denial. A covered individual or the covered individual's authorized representative may appeal Any determination to deny a coverage exemption. 6. A health care insurer, pharmacy benefit manager or utilization review agent contracted to provide pharmacy benefit management services must uphold or reverse a determination to deny a coverage exemption within seventy-two hours after receiving an appeal of denial. In cases where exigent circumstances exist, a health care insurer or pharmacy benefit manager contracted to provide pharmacy benefit management services shall uphold or reverse a determination to deny a coverage exemption within twenty-four hours after receipt if provided with sufficient justification and any supporting clinical documentation. If the determination to deny a coverage exemption is not upheld or reversed on appeal within the application time period, the denial is considered reversed and the coverage exemption is automatically approved. 7. If a determination to deny a coverage exemption is upheld on appeal, the denial shall be considered a final agency action and the covered individual or covered individual's authorized representative may challenge that determination in state court. D. This section does not do any of the following: 1. Prevent a health care professional from prescribing another drug covered by the carrier, the insurer or the pharmacy benefit manager contracted to provide pharmacy benefit management services that the health care professional deems medically necessary for the covered individual. 2. Prevent a health care insurer or pharmacy benefit manager contracted to provide pharmacy benefit management services from either: (a) Adding a prescription drug to its formulary. (b) Removing a prescription drug from its formulary if the drug manufacturer has removed the drug for sale in the United States. E. If a health care insurer, pharmacy benefit manager or utilization review agent contracted to provide pharmacy benefit management services violates this section, the director has authority to take any enforcement action against that health care insurer, pharmacy benefit manager or utilization review agent. f. a policy that is issued or renewed by a DISABILITY insurer does not include a policy that provides limited benefit coverage as defined in section 20-1137. g. For the purposes of this section: 1. "Coverage exemption" means that immediate coverage of a health care provider's selected prescription drug is granted. 2. "Exigent Circumstances" means a health care insurer's, pharmacy benefit manager's or utilization review agent's nonexpedited action on a coverage exemption request could seriously jeopardize the insured's, enrollee's or subscriber's life, health or ability to regain maximum function or cause a significant negative change in medical condition. 3. "Health care insurer" has the same meaning prescribed in section 20-2501. 4. "Health care plan" means a policy, contract or evidence of coverage that a health care insurer issues to an insured, enrollee or subscriber. 5. "Pharmaceutical sample" means a prescription drug that is packaged in small quantities that are consistent with limited dosage therapy of the particular drug and that: (a) Is intended to either: (i) Provide the health care provider with a drug for the immediate need of a patient for a short-term trial purpose. (ii) Be provided to the patient until the patient can fill the prescription drug at a pharmacy. (b) Is not intended to be sold. 6. "Utilization review agent" has the same meaning prescribed in section 20-2530. END_STATUTE Sec. 2. Applicability This act applies to contracts entered into, amended, extended or renewed on or after December 31, 2024.
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7180 Be it enacted by the Legislature of the State of Arizona:
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7382 Section 1. Title 20, chapter 25, article 2, Arizona Revised Statutes, is amended by adding section 20-3335, to read:
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75-START_STATUTE20-3335. Pharmacy benefit managers; prescribing; coverage exemption determination process; enforcement; applicability; definitions
84+START_STATUTE20-3335. Pharmacy benefit managers; prescribing; coverage exemption determination process; enforcement; definitions
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7786 A. If a pharmacy benefit manager enters into an agreement with a health care insurer to provide pharmacy benefit management services to covered individuals, the pharmacy benefit manager, on behalf of the pharmacy benefit manager or a health care insurer:
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79-1. May not limit or exclude coverage of a prescription drug for any covered individual who is on a specific prescription drug if both of the following apply:
88+1. May not limit or exclude coverage of a prescription drug for any covered individual who is medically stable on a specific prescription drug as determined by the covered individual's prescribing health care professional, if both of the following apply:
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8190 (a) The prescription drug was previously approved by the pharmacy benefit manager or health care insurer for coverage for the covered individual.
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8392 (b) The covered individual continues to be an enrollee of the health care insurer that the pharmacy benefit manager has contracted with to provide pharmacy benefit management services.
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85-2. If paragraph 1 of this subsection applies, shall continue coverage of a covered individual's specific prescription drug through the last day of the covered individual's plan year.
94+2. Shall continue coverage of a covered individual's prescription drug as described in paragraph 1 of this subsection through the last day of the covered individual's eligibility under the covered individual's health benefit plan, including any open enrollment period.
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87-B. For the purposes of subsection a of this section, a pharmacy benefit manager, on behalf of the pharmacy benefit manager or a health care insurer, may not do any of the following for a covered individual identified under subsection a of this section:
96+B. For the purposes of subsection A, paragraph 1 of this section, a pharmacy benefit manager, on behalf of the pharmacy benefit manager or a health care insurer, may not do any of the following:
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8998 1. Limit or reduce the maximum coverage of prescription drug benefits.
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91100 2. Increase cost sharing for a covered prescription drug.
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93102 3. Move a prescription drug to a more restrictive formulary tier.
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95104 4. Remove a prescription drug from a formulary unless either of the following applies:
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97106 (a) The United States food and drug administration revokes approval for or removes a prescription drug from the prescription drug market.
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99-(b) the prescription drug manufacturer notifies the united states food and drug administration of a manufacturing discontinuation or a potential discontinuation as required by section 506c of the federal food, drug, and cosmetic act.
108+(b) The prescription drug manufacturer notifies the United States food and drug administration of a manufacturing discontinuation or a potential discontinuation, as required by section 506c of the federal food, drug, and cosmetic act.
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101-C. If a pharmacy benefit manager or health care insurer makes any formulary change during a plan year, the pharmacy benefit manager or health care insurer shall provide written notice of the formulary change for any prescription drug on the drug formulary to each impacted covered individual and the impacted covered individual's prescribing health care provider at least sixty days before the FORMULARY change during the plan year. The pharmacy benefit manager or health care insurer may only change a covered individual from the previously covered prescription drug if the covered individual's prescribing health care provider provides written authorization to the pharmacy benefit manager or health care insurer for the change in the prescription drug.
110+C. A prescription coverage exemption determination process is available to covered individuals and the prescribing health care professional to ensure continuity of care as follows:
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103-D. A pharmacy benefit manager or health care insurer shall provide written notice of the removal from or an increase in cost sharing for any prescription drug on the drug formulary to each impacted covered individual and the impacted covered individual's prescribing health care provider at least sixty days before the end of the plan year, if the covered individual's prescribing health care provider did not previously approve a change in the prescription drug. the notice shall set forth the process by which the covered individual's health care provider may request a prescription drug coverage exemption for the continued use of the nonformulary prescription drug and the exemption process shall comply with subsection e of this section.
112+1. A health care insurer, pharmacy benefit manager or utilization review agent that is contracted to provide pharmacy benefit management services for the health care insurer shall provide a covered individual and prescribing health care professional with access to a clear and convenient process to request a coverage exemption determination. A health care insurer, pharmacy benefit manager or utilization review agent that is contracted to provide pharmacy benefit management services for the health care insurer may use its existing medical exceptions process to satisfy this requirement if the medical exceptions process is consistent with the requirements prescribed in this section.
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105-E. A prescription drug coverage exemption determination process is available to covered individuals and the prescribing health care provider to ensure continuity of care after a covered individual's renewal in the following manner:
114+2. A health care insurer, pharmacy benefit manager or utilization review agent shall respond to a coverage exemption determination request within seventy-two hours after receipt. In cases where exigent circumstances exist, the health care insurer, pharmacy benefit manager or utilization review agent shall respond within twenty-four hours after receipt if provided with sufficient justification and any supporting clinical documentation. If a response by the health care insurer, pharmacy benefit manager or utilization review agent is not received within the applicable time frame, the coverage exemption is automatically granted.
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107-1. A health care insurer, pharmacy benefit manager or utilization review agent that is contracted to provide pharmacy benefit management services for the health care insurer shall provide a covered individual and prescribing health care provider with access to a clear and convenient process to request a coverage exemption determination. The health care insurer, pharmacy benefit manager or utilization review agent may use its existing medical exceptions process to satisfy this requirement if the medical exceptions process is consistent with the requirements prescribed in this section.
116+3. A coverage exemption shall be expeditiously granted for a discontinued health benefit plan, including a health benefit plan from an individual's prior plan year, if a covered individual enrolls in a comparable plan offered by the same group health plan offering group or individual health insurance coverage, and all of the following conditions apply:
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109-2. A health care insurer, pharmacy benefit manager or utilization review agent shall respond to a coverage exemption determination request within the timelines outlined in 45 Code of Federal regulations section 156.122.
118+(a) The covered individual is medically stable on a prescription drug as determined by the covered individual's prescribing health care professional.
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111-3. A health care insurer, pharmacy benefit manager or utilization review agent shall approve a prescription drug coverage exemption for a covered individual who has been previously approved to receive the nonformulary prescription drug by the covered individual's current health care insurer or pharmacy benefit manager and the prescribing health care provider continues to prescribe the prescription drug for the covered individual's medical condition.
120+(b) The prescribing health care professional continues to prescribe the drug for the covered individual for the covered individual's medical condition.
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113-4. Denial of coverage for a health care insurer's or pharmacy benefit manager's denial of coverage for a nonformulary prescription drug shall be made in writing by a licensed pharmacist or medical director. The written denial shall contain an explanation of the denial that includes the medical or pharmacological reasons why the authorization was denied and a signature by the licensed pharmacist or medical director who made the decision to deny coverage. The corporation shall send a copy of the written denial to the covered individual's treating health care provider who requested the authorization. The corporation shall maintain copies of all written denials and shall make the copies available to the department for inspection during regular business hours. A covered individual or the covered individual's authorized representative may appeal any determination to deny a coverage exemption. The written notification shall include the process in which a covered individual may appeal the determination.
122+(c) In comparison to the discontinued health benefit plan, the new health benefit plan does any of the following:
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115-5. If the corporation authorizes a coverage exemption for a covered individual pursuant to this section, that authorization shall be in effect until the end of the covered individual's plan year. The approval of a coverage exemption shall be in writing and delivered to the covered individual and the covered individual's treating health care provider.
124+(i) Limits or reduces the maximum coverage of prescription drug benefits.
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117-F. This section does not:
126+(ii) Increases cost sharing for the prescription drug.
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119-1. Prevent a health care provider from prescribing another prescription drug covered by the carrier, the health care insurer or the pharmacy benefit manager, if the carrier, health care insurer or the pharmacy benefit manager is contracted to provide pharmacy benefit management services and the health care provider deems the prescription drug medically necessary for the covered individual.
128+(iii) Moves the prescription drug to a more restrictive tier if the carrier, insurer or pharmacy benefit manager uses a formulary with tiers.
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121-2. Prevent a health care insurer or pharmacy benefit manager contracted to provide pharmacy benefit management services from:
130+(iv) Excludes the prescription drug from the carrier's, insurer's or pharmacy benefit manager's formulary.
131+
132+4. A coverage exemption shall be expeditiously granted for a covered individual without a discontinued health benefit plan if the covered individual has previously received the prescription drug by any means, including participation in a clinical trial, third-party patient assistance or other financial support programs, and all of the following conditions apply:
133+
134+(a) The covered individual is medically stable on a prescription drug as determined by the covered individual's prescribing health care professional.
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136+(b) The prescribing health care professional continues to prescribe the drug for the covered individual for the covered individual's medical condition.
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138+(c) The prescription drug was not provided as a pharmaceutical sample.
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140+5. If a request for a coverage exemption is denied, the health care insurer, pharmacy benefit manager or utilization review agent contracted to provide pharmacy benefit management services shall provide the covered individual or the covered individual's prescribing health care professional with the reasons for the denial and information regarding the procedure to appeal the denial. A covered individual or the covered individual's authorized representative may appeal Any determination to deny a coverage exemption.
141+
142+6. A health care insurer, pharmacy benefit manager or utilization review agent contracted to provide pharmacy benefit management services must uphold or reverse a determination to deny a coverage exemption within seventy-two hours after receiving an appeal of denial. In cases where exigent circumstances exist, a health care insurer or pharmacy benefit manager contracted to provide pharmacy benefit management services shall uphold or reverse a determination to deny a coverage exemption within twenty-four hours after receipt if provided with sufficient justification and any supporting clinical documentation. If the determination to deny a coverage exemption is not upheld or reversed on appeal within the application time period, the denial is considered reversed and the coverage exemption is automatically approved.
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144+7. If a determination to deny a coverage exemption is upheld on appeal, the denial shall be considered a final agency action and the covered individual or covered individual's authorized representative may challenge that determination in state court.
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146+D. This section does not do any of the following:
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148+1. Prevent a health care professional from prescribing another drug covered by the carrier, the insurer or the pharmacy benefit manager contracted to provide pharmacy benefit management services that the health care professional deems medically necessary for the covered individual.
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150+2. Prevent a health care insurer or pharmacy benefit manager contracted to provide pharmacy benefit management services from either:
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123152 (a) Adding a prescription drug to its formulary.
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125-(b) removing a prescription drug from its formulary if the drug manufacturer has removed the prescription drug for sale in the united states.
154+(b) Removing a prescription drug from its formulary if the drug manufacturer has removed the drug for sale in the United States.
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127-(c) making any formulary changes for patients who are not on a previously approved prescription drug.
156+E. If a health care insurer, pharmacy benefit manager or utilization review agent contracted to provide pharmacy benefit management services violates this section, the director has authority to take any enforcement action against that health care insurer, pharmacy benefit manager or utilization review agent.
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129-g. If a health care insurer, pharmacy benefit manager or utilization review agent that is contracted to provide pharmacy benefit management services violates this section, the director may impose a civil penalty against that health care insurer, pharmacy benefit manager or utilization review agent.
158+f. a policy that is issued or renewed by a DISABILITY insurer does not include a policy that provides limited benefit coverage as defined in section 20-1137.
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131-H. A policy that is issued or renewed by a disability insurer does not include a policy that provides limited benefit coverage as defined in section 20-1137.
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133-i. For the purposes of this section:
160+g. For the purposes of this section:
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135162 1. "Coverage exemption" means that immediate coverage of a health care provider's selected prescription drug is granted.
136163
137-2. "health care insurer" has the same meaning prescribed in section 20-2501.
164+2. "Exigent Circumstances" means a health care insurer's, pharmacy benefit manager's or utilization review agent's nonexpedited action on a coverage exemption request could seriously jeopardize the insured's, enrollee's or subscriber's life, health or ability to regain maximum function or cause a significant negative change in medical condition.
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139-3. "health care plan" means a policy, contract or evidence of coverage that a health care insurer issues to an insured, enrollee or subscriber.
166+3. "Health care insurer" has the same meaning prescribed in section 20-2501.
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141-4. "utilization review agent" has the same meaning prescribed in section 20-2530. END_STATUTE
168+4. "Health care plan" means a policy, contract or evidence of coverage that a health care insurer issues to an insured, enrollee or subscriber.
169+
170+5. "Pharmaceutical sample" means a prescription drug that is packaged in small quantities that are consistent with limited dosage therapy of the particular drug and that:
171+
172+(a) Is intended to either:
173+
174+(i) Provide the health care provider with a drug for the immediate need of a patient for a short-term trial purpose.
175+
176+(ii) Be provided to the patient until the patient can fill the prescription drug at a pharmacy.
177+
178+(b) Is not intended to be sold.
179+
180+6. "Utilization review agent" has the same meaning prescribed in section 20-2530. END_STATUTE
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143182 Sec. 2. Applicability
144183
145184 This act applies to contracts entered into, amended, extended or renewed on or after December 31, 2024.