| (a) An issuer of a health benefit plan that offers
prescription drug benefits must make a prescription drug that was
approved or covered for a medical condition or mental illness available
to each enrollee at the contracted benefit level until the health
benefit plan renewal date. Modifications to drug coverage are not
permitted until the plan's renewal date.
(b) A health benefit plan issuer may make modifications
to drug coverage provided under a health benefit plan if:
(1) the modification occurs at the time of coverage
renewal;
(2) the modification is effective uniformly among all
group health benefit plan sponsors covered by identical or substantially
identical health benefit plans, or all individuals covered by identical
or substantially identical individual health benefit plans, as applicable;
and
(3) not later than the 60th day before the date the
modification is effective, the issuer provides written notice of the
modification to the commissioner, each affected group health benefit
plan sponsor, each affected enrollee in an affected group health benefit
plan, and each affected individual health benefit plan holder for
modifications that:
(A) remove a drug from a formulary;
(B) add a requirement that an enrollee receive prior
authorization for a drug;
(C) impose or alter a quantity limit for a drug;
(D) impose a step-therapy restriction for a drug; or
(E) move a drug to a higher cost-sharing tier unless
a generic drug alternative is available.
(c) For purposes of this section, modifications that
are more favorable to the consumer may be made without notice at any
time, including modifications that:
(1) add drugs to formularies;
(2) reduce cost sharing; or
(3) delete a utilization review requirement.
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