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PRINTER'S NO. 524
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No.
484
Session of
2019
INTRODUCED BY MENSCH, K. WARD, COSTA, COLLETT, TARTAGLIONE AND
BREWSTER, MARCH 28, 2019
REFERRED TO BANKING AND INSURANCE, MARCH 28, 2019
AN ACT
Providing for requirements for insurers relating to prescription
drug coverage; and conferring powers and imposing duties on
the Insurance Department.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Short title.
This act shall be known and may be cited as the Specialty
Tier Prescription Drug Act.
Section 2. Definitions.
The following words and phrases when used in this act shall
have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Health benefit plan." An arrangement for the delivery of
health care, on an individual or group basis, in which a health
care carrier undertakes to provide, arrange for, pay for or
reimburse any of the costs of health care services for a covered
person that is offered or governed under this act or the
following:
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(1) The act of December 29, 1972 (P.L.1701, No.364),
known as the Health Maintenance Organization Act.
(2) The act of May 18, 1976 (P.L.123, No.54), known as
the Individual Accident and Sickness Insurance Minimum
Standards Act.
(3) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations) or 63 (relating to professional health services
plan corporations).
"Nonpreferred prescription drug." A prescription drug deemed
nonpreferred by the health benefit plan and subject to higher
cost sharing than preferred prescription drugs.
"Preferred prescription drug." A prescription drug deemed
preferred by the health benefit plan and subject to lower cost
sharing than nonpreferred prescription drugs.
"Specialty tier prescription drug." A prescription drug for
which a health benefit plan imposes cost sharing in excess of
preferred prescription drugs and nonpreferred prescription
drugs.
"Tiered formulary." A formulary that provides prescription
drug coverage, as part of a health benefit plan, for which cost
sharing is determined by the category or tier of the
prescription drug.
Section 3. Specialty tier prescription drug requirements.
(a) Maximum limitations.--A health benefit plan that
provides coverage for prescription drugs shall ensure that any
required copayment or coinsurance applicable to a specialty tier
prescription drug does not exceed $100 per month for a 30-day
supply of the specialty tier drug. The aggregate cost of all
specialty tier prescription drugs required by an insured may not
exceed $200 per month.
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(b) Classification.--A health benefit plan that provides
coverage for prescription drugs may not place all prescription
drugs of the same class in a specialty tier.
Section 4. Cost-sharing exception.
(a) General rule.--A health benefit plan that provides
coverage for prescription drugs and utilizes a tiered formulary
shall implement an exceptions process that allows an insured to
request an exception to the tiered cost-sharing structure.
(b) Requirements.--To qualify for an exception to the tiered
cost-sharing structure, the insured must provide evidence that
the insured's prescribing physician has determined that:
(1) the preferred prescription drug would not be as
effective as a nonpreferred prescription drug used to treat
the same condition; or
(2) the preferred prescription drug would have adverse
effects for the insured.
(c) Review.--The Insurance Department shall establish and
administer an independent external review process for review of
denials to a cost-sharing exception request.
Section 5. Regulations.
The Insurance Department shall promulgate regulations
necessary to administer this act.
Section 6. Construction.
The following shall apply:
(1) Nothing in this act shall be construed to require a
health benefit plan to:
(i) Provide coverage for any additional prescription
drugs not otherwise required by law.
(ii) Implement specific utilization management
techniques such as prior authorization or step therapy.
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(iii) Cease utilization of tiered cost-sharing
structures, including strategies used to encourage use of
preventive services, disease management and low-cost
treatment options.
(2) Nothing in this act shall be construed to require a
pharmacist to substitute a prescription drug without the
written consent of the prescribing physician.
Section 7. Applicability.
This act shall apply to all health benefit plans delivered or
issued for delivery or renewed on or after the effective date of
this section.
Section 8. Effective date.
This act shall take effect in 60 days.
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