Researcher: JKL Page 1 4/8/21
OLR Bill Analysis
HB 6622
AN ACT CONCERNING PRESCRIPTION DRUG FORMULARIES
AND LISTS OF COVERED DRUGS.
SUMMARY
This bill prohibits health carriers (e.g., insurers and HMOs) offering
a health benefit plan that covers prescription drugs and uses a
formulary (i.e., a list of covered prescription drugs) from removing
from the formulary or moving to a higher cost-sharing tier, any
covered drug during the plan year except as specifically allowed. This
applies regardless of any other general statute provision (see
BACKGROUND).
Under the bill, a carrier may remove a drug from a formulary with
at least 90 days’ advance notice to a covered person and his or her
treating physician if the U.S. Food and Drug Administration (FDA):
1. issues an announcement, guidance, or similar statement
questioning the drug’s clinical safety, unless the treating
physician states in writing that the drug remains medically
necessary for the covered person, or
2. approves the drug for over-the-counter use.
The bill allows a carrier to move a drug to a higher cost-sharing tier
if it is available in-network for $40 or less per month in any tier. It also
allows a carrier to move a brand name drug to a higher cost-sharing
tier if it adds an FDA-approved generic alternative to the formulary at
a lower cost-sharing tier than the brand name drug.
Lastly, the bill specifies that it does not prevent or prohibit a carrier
from adding a prescription drug to a formulary at any time.
EFFECTIVE DATE: January 1, 2022 2021HB-06622-R000348-BA.DOCX
Researcher: JKL Page 2 4/8/21
APPLICABILITY OF THE BILL’S PROVISIONS
The bill generally applies to each insurer, HMO, hospital or medical
service corporation, fraternal benefit society, or other entity that
delivers, issues, renews, amends, or continues individual or group
health insurance policies in Connecticut that cover (1) basic hospital
expenses, (2) basic medical-surgical expenses, (3) major medical
expenses, or (4) hospital or medical services. However, it does not
apply to a grandfathered health plan, which is a plan that existed on
March 23, 2010, and has not made significant coverage changes since.
Because of the federal Employee Retirement Income Security Act
(ERISA), state insurance benefit mandates do not apply to self-insured
benefit plans.
BACKGROUND
Related Law
The law prohibits health carriers that cover outpatient prescription
drugs from denying coverage for any drug removed from a formulary
if (1) an insured person was using the drug to treat a chronic illness
and had been covered for it before the removal and (2) his or her
attending physician states in writing, after the removal, that the drug is
medically necessary and why it is more beneficial than other formulary
drugs (CGS §§ 38a-492f & 38a-518f).
COMMITTEE ACTION
Insurance and Real Estate Committee
Joint Favorable
Yea 18 Nay 0 (03/22/2021)