CT
Connecticut House Bill HB07124

Connecticut 2017 Regular Session

Connecticut House Bill HB07124 Compare Versions

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1-Substitute House Bill No. 7124
1+General Assembly Substitute Bill No. 7124
2+January Session, 2017 *_____HB07124INS___031017____*
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3-Public Act No. 17-55
4+General Assembly
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5-AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR FERTILITY PRESERVATION FOR INSUREDS DIAGNOSED WITH CANCER.
6+Substitute Bill No. 7124
7+
8+January Session, 2017
9+
10+*_____HB07124INS___031017____*
11+
12+AN ACT CONCERNING MAXIMUM ALLOWABLE COST LISTS AND DISCLOSURES BY PHARMACY BENEFITS MANAGERS, LIMITING COST-SHARING FOR PRESCRIPTION DRUGS AND SHIELDING PHARMACISTS AND PHARMACIES FROM CERTAIN PENALTIES.
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714 Be it enacted by the Senate and House of Representatives in General Assembly convened:
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9-Section 1. Section 38a-509 of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2018):
16+Section 1. (NEW) (Effective October 1, 2017) (a) As used in this section, (1) "maximum allowable cost" means the maximum amount a pharmacy benefits manager will reimburse a pharmacy for a prescription drug, and (2) "maximum allowable cost list" means a list of prescription drugs for which a maximum allowable cost has been established by a pharmacy benefits manager.
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11-(a) Subject to the limitations set forth in subsection (b) of this section and except as provided in subsection (c) of this section, each individual health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after [October 1, 2005] January 1, 2018, shall provide coverage for the medically necessary expenses of the diagnosis and treatment of infertility, including, but not limited to, ovulation induction, intrauterine insemination, in-vitro fertilization, uterine embryo lavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer. For purposes of this section, "infertility" means the condition of [a presumably healthy] an individual who is unable to conceive or produce conception or sustain a successful pregnancy during a one-year period or such treatment is medically necessary.
18+(b) (1) Each pharmacy benefits manager shall, prior to placing a prescription drug on a maximum allowable cost list, ensure that such drug (A) (i) has been designated as therapeutically equivalent to other pharmaceutically equivalent products with an "A" code or "B" code in the most recent edition or supplement of the federal Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations, or (ii) has an "NR" rating, "NA" rating or similar rating by a nationally recognized pricing reference, and (B) (i) is available for purchase by pharmacies in this state from national or regional wholesalers, and (ii) is not obsolete or temporarily unavailable. As used in this subparagraph, a drug is obsolete even if it is listed in national drug pricing compendia, if it is no longer actively marketed by the manufacturer or labeler.
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13-(b) Such policy may:
20+(2) Each pharmacy benefits manager shall remove a prescription drug from a maximum allowable cost list not later than three business days after (A) the prescription drug no longer meets the requirements in subdivision (1) of this subsection, or (B) the pharmacy benefits manager becomes aware that such drug no longer meets the requirements in subdivision (1) of this subsection.
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15-(1) Limit such coverage to an individual until the date of such individual's fortieth birthday;
22+(c) Each contract entered into, renewed or amended on or after October 1, 2017, between a pharmacy benefits manager and a pharmacy or a pharmacy's contracting representative or agent shall disclose the sources used by the pharmacy benefits manager to determine the maximum allowable costs for prescription drugs on each maximum allowable cost list for such pharmacy.
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17-(2) Limit such coverage for ovulation induction to a lifetime maximum benefit of four cycles;
24+(d) Each pharmacy benefits manager shall:
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19-(3) Limit such coverage for intrauterine insemination to a lifetime maximum benefit of three cycles;
26+(1) Provide an updated maximum allowable cost list to a plan sponsor whenever there is a change to any such list under the plan;
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21-(4) Limit lifetime benefits to a maximum of two cycles, with not more than two embryo implantations per cycle, for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer or low tubal ovum transfer, provided each such fertilization or transfer shall be credited toward such maximum as one cycle;
28+(2) Update each maximum allowable cost list at least every seven calendar days and promptly notify and make available to each in-network pharmacy any such updated list applicable to such pharmacy; and
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23-(5) Limit coverage for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer to those individuals who have been unable to conceive or produce conception or sustain a successful pregnancy through less expensive and medically viable infertility treatment or procedures covered under such policy. Nothing in this subdivision shall be construed to deny the coverage required by this section to any individual who foregoes a particular infertility treatment or procedure if the individual's physician determines that such treatment or procedure is likely to be unsuccessful;
30+(3) Establish an appeals process for a pharmacy to contest the maximum allowable cost of a prescription drug in accordance with the provisions of subsection (e) of this section. Each pharmacy benefits manager shall provide to each in-network pharmacy information concerning the appeals process.
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25-(6) Require that covered infertility treatment or procedures be performed at facilities that conform to the standards and guidelines developed by the American Society of Reproductive Medicine or the Society of Reproductive Endocrinology and Infertility;
32+(e) (1) A pharmacy may contest the maximum allowable cost of a prescription drug based on one or both of the following grounds:
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27-(7) Limit coverage to individuals who have maintained coverage under such policy for at least twelve months; and
34+(A) The prescription drug does not meet the requirements in subdivision (1) of subsection (b) of this section; or
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29-(8) Require disclosure by the individual seeking such coverage to such individual's existing health insurance carrier of any previous infertility treatment or procedures for which such individual received coverage under a different health insurance policy. Such disclosure shall be made on a form and in the manner prescribed by the Insurance Commissioner.
36+(B) The maximum allowable cost established by the pharmacy benefits manager for the prescription drug is below the cost at which such drug is available for purchase from national or regional wholesalers.
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31-(c) (1) Any insurance company, hospital service corporation, medical service corporation or health care center may issue to a religious employer an individual health insurance policy that excludes coverage for methods of diagnosis and treatment of infertility that are contrary to the religious employer's bona fide religious tenets.
38+(2) A pharmacy contesting the maximum allowable cost of a prescription drug shall file an appeal with the pharmacy benefits manager not later than sixty calendar days after filing its submission for the initial claim for reimbursement for such drug. The pharmacy benefits manager shall investigate and issue a determination of such appeal not later than seven calendar days after such manager receives such appeal.
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33-(2) Upon the written request of an individual who states in writing that methods of diagnosis and treatment of infertility are contrary to such individual's religious or moral beliefs, any insurance company, hospital service corporation, medical service corporation or health care center may issue to or on behalf of the individual a policy or rider thereto that excludes coverage for such methods.
40+(3) If the pharmacy benefits manager determines the appeal is denied, the manager shall provide to the pharmacy the reason for the denial and the national drug code of a therapeutically equivalent prescription drug that is available for purchase by pharmacies in this state from national or regional wholesalers at a price that is equal to or less than the maximum allowable cost for the prescription drug that is the subject of the appeal.
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35-(d) Any health insurance policy issued pursuant to subsection (c) of this section shall provide written notice to each insured or prospective insured that methods of diagnosis and treatment of infertility are excluded from coverage pursuant to said subsection. Such notice shall appear, in not less than ten-point type, in the policy, application and sales brochure for such policy.
42+(4) If the pharmacy benefits manager determines the appeal is valid, such manager shall (A) adjust the maximum allowable cost for such prescription drug, and (B) adjust such maximum allowable cost for the appealing pharmacy not later than five business days after making such determination.
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37-(e) As used in this section, "religious employer" means an employer that is a "qualified church-controlled organization", as defined in 26 USC 3121 or a church-affiliated organization.
44+Sec. 2. Section 38a-510 of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2018):
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39-Sec. 2. Section 38a-536 of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2018):
46+(a) No insurance company, hospital service corporation, medical service corporation, health care center or other entity delivering, issuing for delivery, renewing, amending or continuing an individual health insurance policy or contract that provides coverage for prescription drugs may:
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41-(a) Subject to the limitations set forth in subsection (b) of this section and except as provided in subsection (c) of this section, each group health insurance policy providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 delivered, issued for delivery, amended, renewed or continued in this state on or after [October 1, 2005] January 1, 2018, shall provide coverage for the medically necessary expenses of the diagnosis and treatment of infertility, including, but not limited to, ovulation induction, intrauterine insemination, in-vitro fertilization, uterine embryo lavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer. For purposes of this section, "infertility" means the condition of [a presumably healthy] an individual who is unable to conceive or produce conception or sustain a successful pregnancy during a one-year period or such treatment is medically necessary.
48+(1) Require any person covered under such policy or contract to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for such drugs; [or]
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43-(b) Such policy may:
50+(2) Impose a coinsurance, copayment, deductible or other out-of-pocket expense that exceeds the claim cost of a covered prescription drug, except that a high deductible health plan, as that term is used in subsection (f) of section 38a-493, shall not be subject to the deductible provision set forth in this subdivision until after the minimum annual deductible for such plan has been met; or
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45-(1) Limit such coverage to an individual until the date of such individual's fortieth birthday;
52+[(2)] (3) Require, if such insurance company, hospital service corporation, medical service corporation, health care center or other entity uses step therapy for such drugs, the use of step therapy for any prescribed drug for longer than sixty days. At the expiration of such time period, an insured's treating health care provider may deem such step therapy drug regimen clinically ineffective for the insured, at which time the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract. If such provider does not deem such step therapy drug regimen clinically ineffective or has not requested an override pursuant to subdivision (1) of subsection (b) of this section, such drug regimen may be continued. For purposes of this section, "step therapy" means a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition are to be prescribed.
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47-(2) Limit such coverage for ovulation induction to a lifetime maximum benefit of four cycles;
54+(b) (1) Notwithstanding the sixty-day period set forth in subdivision [(2)] (3) of subsection (a) of this section, each insurance company, hospital service corporation, medical service corporation, health care center or other entity that uses step therapy for such prescription drugs shall establish and disclose to its health care providers a process by which an insured's treating health care provider may request at any time an override of the use of any step therapy drug regimen. Any such override process shall be convenient to use by health care providers and an override request shall be expeditiously granted when an insured's treating health care provider demonstrates that the drug regimen required under step therapy (A) has been ineffective in the past for treatment of the insured's medical condition, (B) is expected to be ineffective based on the known relevant physical or mental characteristics of the insured and the known characteristics of the drug regimen, (C) will cause or will likely cause an adverse reaction by or physical harm to the insured, or (D) is not in the best interest of the insured, based on medical necessity.
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49-(3) Limit such coverage for intrauterine insemination to a lifetime maximum benefit of three cycles;
56+(2) Upon the granting of an override request, the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract.
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51-(4) Limit lifetime benefits to a maximum of two cycles, with not more than two embryo implantations per cycle, for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer or low tubal ovum transfer, provided each such fertilization or transfer shall be credited toward such maximum as one cycle;
58+(c) Nothing in this section shall (1) preclude an insured or an insured's treating health care provider from requesting a review under sections 38a-591c to 38a-591g, inclusive, or (2) affect the provisions of section 38a-492i.
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53-(5) Limit coverage for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer to those individuals who have been unable to conceive or produce conception or sustain a successful pregnancy through less expensive and medically viable infertility treatment or procedures covered under such policy. Nothing in this subdivision shall be construed to deny the coverage required by this section to any individual who foregoes a particular infertility treatment or procedure if the individual's physician determines that such treatment or procedure is likely to be unsuccessful;
60+(d) No individual health insurance carrier may terminate the services of, require additional documentation from, require additional utilization review, reduce payments or otherwise penalize or provide financial disincentives to any pharmacy or pharmacist on the basis that the pharmacy or pharmacist disclosed to an insured information concerning (1) the cost or efficacy of a prescription drug, or (2) any drug that is therapeutically equivalent to a prescription drug.
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55-(6) Require that covered infertility treatment or procedures be performed at facilities that conform to the standards and guidelines developed by the American Society of Reproductive Medicine or the Society of Reproductive Endocrinology and Infertility;
62+Sec. 3. Section 38a-544 of the general statutes is repealed and the following is substituted in lieu thereof (Effective January 1, 2018):
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57-(7) Limit coverage to individuals who have maintained coverage under such policy for at least twelve months; and
64+(a) No insurance company, hospital service corporation, medical service corporation, health care center or other entity delivering, issuing for delivery, renewing, amending or continuing a group health insurance policy or contract that provides coverage for prescription drugs may:
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59-(8) Require disclosure by the individual seeking such coverage to such individual's existing health insurance carrier of any previous infertility treatment or procedures for which such individual received coverage under a different health insurance policy. Such disclosure shall be made on a form and in the manner prescribed by the Insurance Commissioner.
66+(1) Require any person covered under such policy or contract to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for such drugs; [or]
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61-(c) (1) Any insurance company, hospital service corporation, medical service corporation or health care center may issue to a religious employer a group health insurance policy that excludes coverage for methods of diagnosis and treatment of infertility that are contrary to the religious employer's bona fide religious tenets.
68+(2) Impose a coinsurance, copayment, deductible or other out-of-pocket expense that exceeds the claim cost of a covered prescription drug, except that a high deductible health plan, as that term is used in subsection (f) of section 38a-493, shall not be subject to the deductible provision set forth in this subdivision until after the minimum annual deductible for such plan has been met; or
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63-(2) Upon the written request of an individual who states in writing that methods of diagnosis and treatment of infertility are contrary to such individual's religious or moral beliefs, any insurance company, hospital service corporation, medical service corporation or health care center may issue to or on behalf of the individual a policy or rider thereto that excludes coverage for such methods.
70+[(2)] (3) Require, if such insurance company, hospital service corporation, medical service corporation, health care center or other entity uses step therapy for such drugs, the use of step therapy for any prescribed drug for longer than sixty days. At the expiration of such time period, an insured's treating health care provider may deem such step therapy drug regimen clinically ineffective for the insured, at which time the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract. If such provider does not deem such step therapy drug regimen clinically ineffective or has not requested an override pursuant to subdivision (1) of subsection (b) of this section, such drug regimen may be continued. For purposes of this section, "step therapy" means a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition are to be prescribed.
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65-(d) Any health insurance policy issued pursuant to subsection (c) of this section shall provide written notice to each insured or prospective insured that methods of diagnosis and treatment of infertility are excluded from coverage pursuant to said subsection. Such notice shall appear, in not less than ten-point type, in the policy, application and sales brochure for such policy.
72+(b) (1) Notwithstanding the sixty-day period set forth in subdivision [(2)] (3) of subsection (a) of this section, each insurance company, hospital service corporation, medical service corporation, health care center or other entity that uses step therapy for such prescription drugs shall establish and disclose to its health care providers a process by which an insured's treating health care provider may request at any time an override of the use of any step therapy drug regimen. Any such override process shall be convenient to use by health care providers and an override request shall be expeditiously granted when an insured's treating health care provider demonstrates that the drug regimen required under step therapy (A) has been ineffective in the past for treatment of the insured's medical condition, (B) is expected to be ineffective based on the known relevant physical or mental characteristics of the insured and the known characteristics of the drug regimen, (C) will cause or will likely cause an adverse reaction by or physical harm to the insured, or (D) is not in the best interest of the insured, based on medical necessity.
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67-(e) As used in this section, "religious employer" means an employer that is a "qualified church-controlled organization", as defined in 26 USC 3121 or a church-affiliated organization.
74+(2) Upon the granting of an override request, the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract.
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76+(c) Nothing in this section shall (1) preclude an insured or an insured's treating health care provider from requesting a review under sections 38a-591c to 38a-591g, inclusive, or (2) affect the provisions of section 38a-518i.
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78+(d) No group health insurance carrier may terminate the services of, require additional documentation from, require additional utilization review, reduce payments or otherwise penalize or provide financial disincentives to any pharmacy or pharmacist on the basis that the pharmacy or pharmacist disclosed to an insured information concerning (1) the cost or efficacy of a prescription drug, or (2) any drug that is therapeutically equivalent to a prescription drug.
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80+Sec. 4. Section 38a-479aaa of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2017):
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82+As used in this section and sections 38a-479bbb to 38a-479iii, inclusive, and section 1 of this act:
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84+(1) "Commissioner" means the Insurance Commissioner;
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86+(2) "Department" means the Insurance Department;
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88+(3) "Drug" means drug, as defined in section 21a-92;
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90+(4) "Person" means person, as defined in section 38a-1;
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92+(5) "Pharmacist services" includes (A) drug therapy and other patient care services provided by a licensed pharmacist intended to achieve outcomes related to the cure or prevention of a disease, elimination or reduction of a patient's symptoms, and (B) education or intervention by a licensed pharmacist intended to arrest or slow a disease process;
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94+(6) "Pharmacist" means an individual licensed to practice pharmacy under section 20-590, 20-591, 20-592 or 20-593, and who is thereby recognized as a health care provider by the state of Connecticut;
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96+(7) "Pharmacy" means a place of business where drugs may be sold at retail and for which a pharmacy license has been issued to an applicant pursuant to section 20-594; and
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98+(8) "Pharmacy benefits manager" or "manager" means any person that administers the prescription drug, prescription device, pharmacist services or prescription drug and device and pharmacist services portion of a health benefit plan on behalf of plan sponsors such as self-insured employers, insurance companies, labor unions and health care centers.
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100+Sec. 5. Section 38a-479hhh of the general statutes is repealed and the following is substituted in lieu thereof (Effective October 1, 2017):
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102+(a) The commissioner may conduct investigations and hold hearings on any matter under the provisions of sections 38a-479aaa to 38a-479iii, inclusive, as amended by this act, or section 1 of this act. The commissioner may issue subpoenas, administer oaths, compel testimony and order the production of books, records and documents. If any person refuses to appear, to testify or to produce any book, record, paper or document when so ordered, upon application of the commissioner, a judge of the Superior Court may make such order as may be appropriate to aid in the enforcement of this section.
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104+(b) Any person aggrieved by an order or decision of the commissioner under sections 38a-479aaa to 38a-479iii, inclusive, as amended by this act, or section 1 of this act may appeal therefrom in accordance with the provisions of section 4-183.
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109+This act shall take effect as follows and shall amend the following sections:
110+Section 1 October 1, 2017 New section
111+Sec. 2 January 1, 2018 38a-510
112+Sec. 3 January 1, 2018 38a-544
113+Sec. 4 October 1, 2017 38a-479aaa
114+Sec. 5 October 1, 2017 38a-479hhh
115+
116+This act shall take effect as follows and shall amend the following sections:
117+
118+Section 1
119+
120+October 1, 2017
121+
122+New section
123+
124+Sec. 2
125+
126+January 1, 2018
127+
128+38a-510
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130+Sec. 3
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132+January 1, 2018
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134+38a-544
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136+Sec. 4
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138+October 1, 2017
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140+38a-479aaa
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142+Sec. 5
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144+October 1, 2017
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146+38a-479hhh
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148+
149+
150+INS Joint Favorable Subst.
151+
152+INS
153+
154+Joint Favorable Subst.