PRINTER'S NO. 1137
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No.
828
Session of
2019
INTRODUCED BY LEACH, FONTANA, SCHWANK AND STREET,
AUGUST 15, 2019
REFERRED TO BANKING AND INSURANCE, AUGUST 15, 2019
AN ACT
Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
act relating to insurance; amending, revising, and
consolidating the law providing for the incorporation of
insurance companies, and the regulation, supervision, and
protection of home and foreign insurance companies, Lloyds
associations, reciprocal and inter-insurance exchanges, and
fire insurance rating bureaus, and the regulation and
supervision of insurance carried by such companies,
associations, and exchanges, including insurance carried by
the State Workmen's Insurance Fund; providing penalties; and
repealing existing laws," in casualty insurance, providing
for cap on payments for prescription insulin drugs.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The act of May 17, 1921 (P.L.682, No.284), known
as The Insurance Company Law of 1921, is amended by adding a
section to read:
Section 634.1. Cap on Payments for Prescription Insulin
Drugs.--(a) An insurance company that provides coverage for
prescription insulin drugs under a health insurance policy shall
cap the total amount that a covered person is required to pay
for covered prescription insulin drugs at an amount not to
exceed one hundred dollars ($100) per thirty-day supply of the
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covered prescription insulin drugs. The default cap shall apply
regardless of the amount or type of insulin needed to fill the
covered person's prescription.
(b) No later than one year after the effective date of this
section and each year thereafter, the Insurance Commissioner
shall adjust the default cap based on the annual cost-of-living
adjustment calculated by applying the percentage change in the
Consumer Price Index for All Urban Consumers (CPI-U) for the
Pennsylvania, New Jersey, Delaware and Maryland area for the
most recent twelve-month period for which figures have been
officially reported by the United States Department of Labor,
Bureau of Labor Statistics. The Insurance Commissioner shall
transmit notice of an adjustment under this subsection to the
Legislative Reference Bureau for publication in the Pennsylvania
Bulletin. An adjustment under this subsection shall take effect
ninety days after the notice of the adjustment is published in
the Pennsylvania Bulletin.
(c) No later than one year after the effective date of this
section and each year thereafter, the Insurance Commissioner, in
conjunction with the Secretary of Health, may establish a
consensus cap on the total amount that a covered person is
required to pay for covered prescription insulin drugs. A
consensus cap must be at least ninety per centum (90%) and no
more than one hundred ten per centum (110%) of the effective
cap. Upon establishing a consensus cap, renewing or failing to
renew a consensus cap, the Insurance Commissioner shall transmit
notice of the effective cap to the Legislative Reference Bureau
for publication in the Pennsylvania Bulletin. If the Insurance
Commissioner, in conjunction with the Secretary of Health, fails
to renew a consensus cap, the consensus cap shall expire and the
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default cap shall take effect.
(d) Nothing in this section shall be construed to prevent an
insurance company from reducing a covered person's cost sharing
by an amount greater than the amount specified by the default
cap or the consensus cap.
(e) As used in this section, the following words and phrases
shall have the meanings given to them in this subsection unless
the context clearly indicates otherwise:
"Consensus cap." The cap on the total amount that a covered
person is required to pay for covered prescription insulin drugs
established under subsection (c).
"Cost sharing." The cost to an individual insured under a
health insurance policy according to any coverage limit,
copayment, coinsurance, deductible or other out-of-pocket
expense requirements imposed by the policy, contract or
agreement.
"Default cap." The cap on the total amount that a covered
person is required to pay for covered prescription insulin drugs
under subsection (a) or the adjusted cap under subsection (b).
"Effective cap." The default cap or the consensus cap on the
total amount that a covered person is required to pay for
covered prescription insulin drugs in effect under a health
insurance policy.
"Health insurance policy." Any individual or group health,
sickness or accident policy, or subscriber contract or
certificate offered, issued or renewed by an entity subject to
one of the following:
(1) This act.
(2) The act of December 29, 1972 (P.L.1701, No.364), known
as the "Health Maintenance Organization Act."
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(3) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations) or 63 (relating to professional health services
plan corporations).
The term does not include accident only, fixed indemnity,
limited benefit, credit, dental, vision, specified disease,
Medicare supplement, Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS) supplement, long-term care or
disability income, workers' compensation or automobile medical
payment insurance.
"Prescription insulin drug." A prescription as defined in 28
Pa. Code ยง 25.51 (relating to definition of "prescription") that
contains insulin and is used to treat diabetes.
Section 2. This act shall take effect in 60 days.
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