Researcher: JKL Page 1 4/7/22
OLR Bill Analysis
sHB 5386
AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR
EPINEPHRINE CARTRIDGE INJECTORS, HEALTH CARRIERS AND
PHARMACY BENEFIT MANAGERS.
SUMMARY
This bill (1) requires certain individual and group health insurance
policies that cover outpatient prescription drugs to cover at least one
epinephrine cartridge injector (e.g., EpiPen) and (2) caps an insured’s
cost sharing (e.g., copayment, coinsurance, or deductible) for the
injector at $25. (It is unclear if the coverage requirement is for at least
one injector each year or for the lifetime of the policy.)
By law, an “epinephrine cartridge injector” is an automatic prefilled
cartridge injector or similar injectable device used to deliver
epinephrine in a standard dose as an emergency first aid response to
allergic reactions.
Additionally, the bill requires each contract between a health carrier
(e.g., insurer or HMO) and a pharmacy benefits manager (PBM) that
requires the PBM to administer a health care plan’s pharmacy benefits
on the carrier’s behalf to also require the PBM to include at least one
covered epinephrine cartridge injector in the lowest cost-sharing tier if
it uses a tiered prescription drug formulary (i.e., list of covered drugs).
EFFECTIVE DATE: January 1, 2023
APPLICABILITY OF INSURANCE COVERAGE REQUIREMENT
The bill’s coverage requirement applies to fully-insured individual
and group health insurance policies delivered, issued, renewed,
amended, or continued in Connecticut on or after January 1, 2023, that
cover (1) basic hospital expenses; (2) basic medical-surgical expenses; (3)
major medical expenses; (4) hospital or medical services, including
those provided under an HMO plan; or (5) single service ancillary 2022HB-05386-R000374-BA.DOCX
Researcher: JKL Page 2 4/7/22
coverage, including prescription drug coverage. Because of the federal
Employee Retirement Income Security Act (ERISA), state insurance
benefit mandates do not apply to self-insured benefit plans.
APPLICABILITY OF COST-SHARING LIMITATION
The bill’s cost-sharing limitation applies to each plan described
above. However, for plans that are high deductible health plans
(HDHPs), it applies only to the maximum extent (1) permitted by
federal law and (2) that does not disqualify someone who establishes a
health savings account (HSA), medical savings account (MSA), or
Archer MSA from receiving the associated federal tax benefits. Under
federal law, individuals with eligible HDHPs may make pre-tax
contributions to an HSA, MSA, or Archer MSA and use the account for
qualified medical expenses.
COMMITTEE ACTION
Insurance and Real Estate Committee
Joint Favorable Substitute
Yea 16 Nay 1 (03/22/2022)