THE SENATE

S.B. NO.

301

TWENTY-EIGHTH LEGISLATURE, 2015

S.D. 2

STATE OF HAWAII

 

 

 

 

 

 

A BILL FOR AN ACT

 

 

RELATING TO HEALTH.

 

 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

 


     SECTION 1.  Chapter 431, Hawaii Revised Statutes, is amended by adding a new section to article 10A to be appropriately designated and to read as follows:

     "§431:10A-    Formulary; accessibility requirements.  (a)  Each accident and health or sickness insurer offering or renewing comprehensive medical plans on or after January 1, 2017, shall:

     (1)  Post the formulary for the plan on the insurer's website in a manner that is accessible and searchable by insureds, potential insureds, and providers;

     (2)  Update the formulary on the insurer's website no later than seventy-two hours after making a change to the formulary;

     (3)  Use a standard formulary template pursuant to subsection (d) to display the formulary or formularies for each product offered by the plan; and

     (4)  Prior to the beginning of the open enrollment period, provide information required by this section prior to the beginning of the open enrollment period via a public website and through a toll-free number that is posted on the insurer's website.

     (b)  Each insurer posting the formulary pursuant to subsection (a) shall include all of the following:

     (1)  Any prior authorization, step edit requirements, or utilization management edits for each specific drug included on the formulary;

     (2)  If the plan uses a tier-based formulary, the plan shall specify for each drug listed on the formulary the specific tier the drug occupies and list the specific co-payments for each tier in the evidence of coverage;

     (3)  For prescription drugs covered under the plan's medical benefit and typically administered by a provider, the plan shall disclose to insureds and potential insureds all covered drugs and any cost-sharing imposed such drugs.  This information may be provided as part of the plan's formulary pursuant to subsection (a) or via a toll-free number that is staffed at least during normal business hours; and

     (4)  For each prescription drug included on the formulary under paragraph (1) or (2) that is subject to a coinsurance and dispensed at an in-network pharmacy, the plan shall:

         (A)  Disclose the dollar amount of the insured's or potential insured's cost-sharing; or

         (B)  Provide a dollar amount range of cost-sharing for an insured or potential insured for each specific drug included on the formulary, as follows:

              (i)  Under $100 - $;

             (ii)  $100-$250 - $$;

            (iii)  $251-$500 - $$$;

             (iv)  $501-$1,000 - $$$$; and

              (v)  Over $1,000.

          If the insurer allows the option for mail order pharmacy, the insurer shall separately list the range of cost-sharing for an insured or potential insured if the insured or potential insured purchases the drug through a mail order facility utilizing the same ranges as provided in this subsection; and

     (5)  Detail whether the prescription drugs are included or excluded from the deductible and detail whether cost-sharing applies to the deductible.

     (c)  Each insurer subject to this section shall, no later than thirty days after the offer or renewal date, attest to the insurance commissioner that the insurer has satisfied the requirements of this section.

     (d)  The commissioner may develop a standard formulary template pursuant to this section.  If the commissioner develops a template, a health care service plan shall use the template to comply with the provisions of this section.

     (e)  For the purposes of this section, "formulary" means the complete list of drugs preferred for use and eligible for coverage under a policy including drugs covered under the policy's pharmacy benefit and medical benefit as defined by the insurance commissioner."

     SECTION 2.  Chapter 432, Hawaii Revised Statutes, is amended by adding a new section to article 1 to be appropriately designated and to read as follows:

     "§432:1-    Formulary; accessibility requirements.  (a)  Each mutual benefit society that issues or renews a hospital or medical service plan on or after January 1, 2017, shall:

     (1)  Post the formulary for the plan on the mutual benefit society's website in a manner that is accessible and searchable by members, potential members, and providers;

     (2)  Update the formulary for the plan on the mutual benefit society's website no later than seventy-two hours after making a change to the formulary;

     (3)  Use a standard formulary template pursuant to subsection (d) to display the formulary or formularies for each product offered by the plan; and

     (4)  Prior to the beginning of the open enrollment period, provide information required by this section prior to the beginning of the open enrollment period via a public website and through a toll-free number that is posted on the mutual benefit society's website.

     (b)  Each mutual benefit society posting the formulary pursuant to subsection (a) shall include all of the following:

     (1)  Any prior authorization, step edit requirements, or utilization management edits for each specific drug included on the formulary;

     (2)  If the plan uses a tier-based formulary, the plan shall specify for each drug listed on the formulary the specific tier the drug occupies and lists the specific co-payments for each tier in the evidence of coverage;

     (3)  For prescription drugs covered under the plan's medical benefit and typically administered by a provider, the plan shall disclose to members and potential members all covered drugs and any cost-sharing imposed such drugs.  This information may be provided as part of the plan's formulary pursuant to subsection (a) or via a toll-free number that is staffed at least during normal business hours; and

     (4)  For each prescription drug included on the formulary under paragraph (1) or (2) that is subject to a coinsurance and dispensed at an in-network pharmacy, the plan shall:

         (A)  Disclose the dollar amount of the member's or potential member's cost-sharing; or

         (B)  Provide a dollar amount range of cost-sharing for a member or potential member for each specific drug included on the formulary, as follows:

              (i)  Under $100 - $;

             (ii)  $100-$250 - $$;

            (iii)  $251-$500 - $$$;

             (iv)  $501-$1,000 - $$$$; and

              (v)  Over $1,000.

          If the mutual benefit society allows the option for mail order pharmacy, the mutual benefit society shall separately list the range of cost-sharing for a member or potential member if the member or potential member purchases the drug through a mail order facility utilizing the same ranges as provided in this subsection; and

     (5)  Detail whether the prescription drugs are included or excluded from the deductible and detail whether cost-sharing applies to the deductible.

 

     (c)  Each mutual benefit society subject to this section shall, no later than thirty days after the offer or renewal date, attest to the insurance commissioner that the mutual benefit society has satisfied the requirements of this section.

     (d)  The commissioner may develop a standard formulary template pursuant to this section.  If the commissioner develops a template, a mutual benefit society shall use the template to comply with the provisions of this section.

     (e)  For the purposes of this section, "formulary" means the complete list of drugs preferred for use and eligible for coverage under a plan, including drugs covered under the plan's pharmacy benefit and medical benefit as defined by the insurance commissioner."

     SECTION 3.  Section 432D-23, Hawaii Revised Statutes, is amended to read as follows:

     "§432D-23  Required provisions and benefits.  Notwithstanding any provision of law to the contrary, each policy, contract, plan, or agreement issued in the State after January 1, 1995, by health maintenance organizations pursuant to this chapter, shall include benefits provided in sections 431:10-212, 431:10A-115, 431:10A-115.5, 431:10A-116, 431:10A-116.2, 431:10A-116.5, 431:10A-116.6, 431:10A-119, 431:10A-120, 431:10A-121, 431:10A-122, 431:10A-125, 431:10A-126, [431:10A-122, and 431:10A-116.2,] 431:10A‑   , and chapter 431M."

     SECTION 4.  Statutory material to be repealed is bracketed and stricken.  New statutory material is underscored.

     SECTION 5.  This Act shall take effect on July 1, 2050.

 


 


 

Report Title:

Formulary; Posting Requirements; Insurers; Health Plan

 

Description:

Requires entities that offer or renew certain health plans on or after January 1, 2017, to make available a complete and updated formulary to enrollees, potential enrollees, and providers.  Effective 7/1/2050.  (SD2)

 

 

 

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