| |
|
| |
| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
| |
| HOUSE BILL |
|
| |
| |
| INTRODUCED BY VEREB, SAYLOR, GINGRICH, CALTAGIRONE, BRENNAN, DALEY, FABRIZIO, GEORGE, HELM, JOSEPHS, MILLARD, PICKETT, VULAKOVICH AND WAGNER, JUNE 6, 2011 |
| |
| |
| REFERRED TO COMMITTEE ON INSURANCE, JUNE 6, 2011 |
| |
| |
| |
| AN ACT |
| |
1 | Providing requirements for insurers relating to prescription |
2 | drug coverage. |
3 | The General Assembly of the Commonwealth of Pennsylvania |
4 | hereby enacts as follows: |
5 | Section 1. Legislative findings and intent. |
6 | (a) Findings.--The General Assembly finds as follows: |
7 | (1) As prescription drug prices continue to escalate, |
8 | other states have experienced the creation by insurers of a |
9 | new cost-sharing mechanism known as prescription drug |
10 | specialty tiers. |
11 | (2) Many insurers use a three-tiered drug formulary |
12 | structure that provides fixed cost prescription drug benefits |
13 | to insureds, based on generic, brand-name preferred and |
14 | brand-name nonpreferred designations. |
15 | (3) Specialty tiers include the costly prescription |
16 | drugs to which some insurers are instituting percentage cost |
17 | prescription drug benefits that are causing some insureds to |
|
1 | pay more than $3,000 for one month's supply of medication. |
2 | (4) Such drugs are typically new, infusible biologics or |
3 | plasma-derived therapies produced in lesser quantities than |
4 | other drugs and not available as less costly brand name or |
5 | generic prescription drugs. |
6 | (5) The cost-sharing, deductible and coinsurance |
7 | obligations for certain drugs have become cost prohibitive |
8 | for insureds trying to overcome serious disease such as |
9 | cancer, hemophilia, multiple sclerosis, myositis, neuropathy, |
10 | primary immunodeficiency disease and rheumatoid arthritis. |
11 | (6) Insurers are also increasing prescription drug |
12 | copays to amounts beyond the reach of most insureds and if an |
13 | insurer utilizes the three-tiered drug formulary, the amounts |
14 | charged for brand-name nonpreferred and specialty drug copays |
15 | should not have the effect of unfairly denying access to |
16 | prescription drugs covered by the health benefit plan and |
17 | should not cost more than is necessary to provide a |
18 | reasonable incentive for insureds to use brand-name preferred |
19 | prescription drugs. |
20 | (7) Paying hundreds or even thousands of dollars each |
21 | month for prescription drugs would be a strain for any |
22 | person, but for people with chronic illnesses and life- |
23 | threatening conditions, this unfortunate social policy has |
24 | the potential to destroy a family's financial solvency or end |
25 | the ability to take a necessary medication. Specialty tiers |
26 | are contrary to the original purpose of insurance, which was |
27 | the spreading of costs. Specialty tiers create a structure |
28 | where those who are sickest pay more, and those who are |
29 | healthy pay less, thus, the creation of specialty tiers is a |
30 | discriminatory practice. |
|
1 | (b) Intent.--It is the intent of the General Assembly that |
2 | every insured have access to reasonable prescription drug |
3 | benefits and that the creation of specialty tiers will prevent |
4 | the achievement of that intent. |
5 | Section 2. Definitions. |
6 | The following words and phrases when used in this act shall |
7 | have the meanings given to them in this section unless the |
8 | context clearly indicates otherwise: |
9 | "Health benefits plan." An arrangement for the delivery of |
10 | health care, on an individual or group basis, in which a health |
11 | carrier undertakes to provide, arrange for, pay for or reimburse |
12 | any of the costs of health care services for a covered person |
13 | that is offered or governed under this act or the following: |
14 | (1) The act of December 29, 1972 (P.L.1701, No.364), |
15 | known as the Health Maintenance Organization Act. |
16 | (2) The act of May 18, 1976 (P.L.123, No.54), known as |
17 | the Individual Accident and Sickness Insurance Minimum |
18 | Standards Act. |
19 | (3) 40 Pa.C.S. Ch. 61 (relating to hospital plan |
20 | corporations) or 63 (relating to professional health services |
21 | plan corporations). |
22 | "Insurer." An insurer delivering, issuing for delivery or |
23 | renewing in this Commonwealth a health benefit plan that |
24 | provides prescription drug coverage. |
25 | Section 3. Prohibitions. |
26 | (a) Payment restrictions.--An insurer shall not create |
27 | specialty tiers that require payment of a percentage cost of |
28 | prescription drugs. |
29 | (b) Copay restrictions.--An insurer shall not establish |
30 | tiers of prescription drug copays in which the maximum |
|
1 | prescription drug copay exceeds by more than 500% the lowest |
2 | prescription drug copay charged under the health benefit plan. |
3 | (c) Out-of-pocket expense.--If an insurer's health benefit |
4 | plan provides a limit for out-of-pocket expenses for benefits |
5 | other than prescription drugs, the insurer shall include one of |
6 | the following provisions in the plan that would result in the |
7 | lowest out-of-pocket prescription drug cost to the insured: |
8 | (1) out-of-pocket expenses for prescription drugs shall |
9 | be included under the plan's total limit for out-of-pocket |
10 | expenses for all benefits provided under the plan; or |
11 | (2) out-of-pocket expenses for prescription drugs per |
12 | contract year shall not exceed $1,000 per insured or $2,000 |
13 | per insured family, adjusted for inflation. |
14 | Section 4. Applicability. |
15 | This act shall apply to all health benefit plans delivered or |
16 | issued for delivery or renewed on or after January 1, 2012. |
17 | Section 5. Regulations. |
18 | Except as provided in section 6, the Insurance Department |
19 | shall enforce this act. The department shall promulgate rules |
20 | and regulations to carry out the purposes of this act. |
21 | Section 6. Additional costs. |
22 | The Insurance Department shall cease enforcement of this act |
23 | if it determines that the requirements of this act will result |
24 | in the assumption by the Commonwealth of additional costs |
25 | pursuant to section 10104(e) of Title X of the Patient |
26 | Protection and Affordable Care Act (Public Law 111-148). |
27 | Section 7. Effective date. |
28 | This act shall take effect in 60 days. |
|