Health; formulary changes prohibited during the plan year.
Impact
This bill significantly impacts existing healthcare regulations, especially relating to the operations of health plans and their formularies. Under the proposed law, health plans may only alter their formularies under specific circumstances, including when a drug is deemed unsafe by the FDA or alternative, cheaper medications are made available. This regulatory change aims to protect enrollees from being subjected to unexpected drug removals or financial burdens within a plan year, theoretically helping maintain their continuity of care and medication adherence.
Summary
House Bill HF1652 seeks to mandate that health plans cannot remove drugs from their formularies nor increase costs for enrollees for medications that have been prescribed during the plan year. This legislation aims to provide stability and predictability for patients, ensuring they can continue their prescribed treatments without the fear of sudden changes to drug availability or cost structures. By making this provision effective from January 1, 2026, it emphasizes a clear transition period for health plans to adjust their operations accordingly.
Conclusion
In summary, HF1652 aims to provide stronger protections for enrollees against formulary changes during a plan year, which can have significant implications for healthcare access and affordability. Its passage could represent a shift towards more consumer-centric policies in health insurance, reflecting an increased legislative focus on patient experiences within the healthcare system.
Contention
Notably, there may be points of contention surrounding HF1652, focusing on the balance between protecting patients and maintaining the flexibility of health plans to manage their formularies. Opponents might argue that such restrictions could stifle the ability of health plans to adapt to new medical evidence and potentially limit their ability to negotiate better pricing with drug manufacturers. Conversely, proponents emphasize the necessity of patient protection and the importance of stable access to medications, especially for those with chronic conditions reliant on specific treatments.
Similar To
Certain formulary changes during the plan year prohibition provision and medical assistance program formulary changes implementation for certain enrollees prohibition provision
Manufacturers required to report and maintain prescription drug prices, filing of health plan prescription drug formularies required, health care coverage provisions modified, prescription benefit tool requirements established, and prescription drug benefit transparency and disclosure required.
Pharmacists authorized to prescribe, dispense, and administer drugs to prevent acquisition of human immunodeficiency virus; pharmacists authorized to order, conduct, and interpret laboratory tests necessary for therapy that uses drugs to prevent acquisition of human immunodeficiency virus.
Health care service prior authorization and coverage requirements modified, ground for disciplinary action against physicians modified, reports to the commissioner of commerce and the legislature required, data classified, and rulemaking authorized.
Prior authorization and coverage of health services requirements modification; ground for disciplinary action against physicians modification; commissioner of commerce and legislature report requirements; classifying data
Pharmacy benefit managers and health carriers required to include lower-cost drugs in their formularies, and formulary structure and formulary tiering for each health plan required to give preference to drug with lowest out-of-pocket cost to patient.