HOUSE OF REPRESENTATIVES

H.B. NO.

15

THIRTY-FIRST LEGISLATURE, 2021

 

STATE OF HAWAII

 

 

 

 

 

 

A BILL FOR AN ACT

 

 

RELATING TO HEALTH.

 

 

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

 


SECTION 1. The legislature finds that the costs of specialty drugs are increasing. Health plans have created a cost-sharing mechanism known as specialty tiers, which greatly increase the potential financial burden on patients.

The legislature further finds that high out-of-pocket costs for specialty drugs could preclude patients from complying with the treatment protocols prescribed by their doctors. The increased cost-sharing associated with specialty tier drugs presents a significant financial strain on very ill individuals and their families. The financial burden of specialty drugs affects patients facing serious health conditions, including hemophilia, human immunodeficiency virus (HIV), hepatitis, multiple sclerosis, lupus, some cancers, and rheumatoid arthritis, among others.

The purpose of this Act is to:

(1) Impose dollar limits on specialty tiers in order to protect patients from unaffordable coinsurance or copayment amounts;

(2) Limit patients' coinsurance or copayment fees for specialty tier drugs to $150 per month for up to a thirty day period supply of any single specialty tier drug; and

(3) Allow patients to request an exception to obtain a specialty drug that would not otherwise be available on a health plan formulary.

SECTION 2. Chapter 431:10A, Hawaii Revised Statutes, is amended by adding a new section to part I to be appropriately designated and to read as follows:

"431:10A-A Specialty tier prescription coverage. (a) All individual and group accident and health or sickness insurance policies that provide coverage for prescription drugs and use a specialty drug tier shall ensure that any required copayment or coinsurance applicable to specialty drugs on a specialty drug tier does not exceed $150 per month for each specialty drug, up to a thirty day supply of any single drug.

(b) All individual and group accident and health or sickness insurance policies that provide coverage for prescription drugs and use a specialty drug formulary shall implement an exceptions process that allows insureds to request an exception to the formulary. Under this type of exception, a non-formulary specialty drug may be deemed covered under the formulary if the prescribing physician determines that the formulary drug for treatment of the same condition would not be as effective for the insured, would have adverse effects for the insured, or both. If an insured is denied an exception, the insured may pursue an internal appeal pursuant to section 432E-5 and an external review pursuant to section 432E-34.

(c) All individual and group accident and health or sickness insurance policies that provide coverage for prescription drugs shall be prohibited from placing all drugs in a given class of drugs on a specialty drug tier.

(d) Nothing in this section shall be construed to require an insurance policy to:

(1) Provide coverage for any additional drugs not otherwise required by law;

(2) Implement specific utilization management techniques, such as prior authorization or step therapy; or

(3) Cease use of tiered cost-sharing structures, including those strategies used to incentivize use of preventive services, disease management, and low-cost treatment options.

(e) Nothing in this section shall be construed to require a pharmacist to substitute a drug without the consent of the prescribing physician.

(f) Nothing contained in any other provision of law or rule shall preclude an insurance policy subject to this chapter from requiring specialty drugs to be obtained through a designated pharmacy or other source of those drugs.

(g) The commissioner may adopt rules regarding the enforcement processes for this section.

(h) As used in this section, unless the context otherwise requires:

"Class of drugs" means a group of medications having similar actions designed to treat a particular disease process.

"Coinsurance" means a cost-sharing amount set as a percentage of the total cost of a drug.

"Commissioner" means the insurance commissioner.

"Copayment" means a cost-sharing amount set as a dollar value.

"Non-preferred drug" means a specialty drug formulary classification for certain specialty drugs deemed non-preferred and therefore subject to limits on eligibility for coverage or to higher cost-sharing amounts than preferred specialty drugs.

"Preferred drug" means a specialty drug formulary classification for certain specialty drugs deemed preferred and therefore not subject to limits on eligibility for coverage or not subject to higher cost-sharing amounts than non-preferred specialty drugs.

"Specialty drug" means a prescription drug:

(1) That is prescribed for a person with:

(A) A complex or chronic medical condition that is a physical, behavioral, or developmental condition that may have no known cure, is progressive, or can be debilitating or fatal if left untreated or undertreated, such as multiple sclerosis, hepatitis C, or rheumatoid arthritis; or

(B) A rare medical disease or condition that affects fewer than two hundred thousand persons in the United States, or fewer than one in one thousand five hundred people, such as cystic fibrosis, hemophilia, or multiple myeloma;

(2) That has a total monthly prescription cost of no less than $600;

(3) That is not stocked at a majority of retail pharmacies; and

(4) For which at least one of the following applies:

(A) The drug is an oral, injectable, or infusible drug product;

(B) The drug has unique storage or shipment requirements, such as refrigeration; or

(C) Patients receiving the drug require education and support beyond traditional dispensing activities.

"Specialty drug formulary" means a specialty drug benefit design that distinguishes, for purposes of eligibility for coverage or for cost-sharing, between preferred drugs and non-preferred drugs.

"Specialty drug tier" means a tier of cost-sharing designed for specialty drugs that exceeds the amount for non-specialty drugs and that the cost-sharing amount is based on coinsurance."

SECTION 3. Chapter 431:10A, Hawaii Revised Statutes, is amended by adding a new section to part II to be appropriately designated and to read as follows:

"431:10A-B Specialty tier prescription coverage. (a) All group or blanket disability insurance policies that provide coverage for prescription drugs and use a specialty drug tier shall ensure that any required copayment or coinsurance applicable to specialty drugs on a specialty drug tier does not exceed $150 per month for each specialty drug, up to a thirty day supply of any single drug.

(b) All group or blanket disability insurance policies that provide coverage for prescription drugs and use a specialty drug formulary shall implement an exceptions process that allows insureds to request an exception to the formulary. Under this type of exception, a non-formulary specialty drug may be deemed covered under the formulary if the prescribing physician determines that the formulary drug for treatment of the same condition would not be as effective for the insured, would have adverse effects for the insured, or both. If an insured is denied an exception, the insured may pursue an internal appeal pursuant to section 432E-5 and an external review pursuant to section 432E-34.

(c) All group or blanket disability insurance policies that provide coverage for prescription drugs shall be prohibited from placing all drugs in a given class of drugs on a specialty drug tier.

(d) Nothing in this section shall be construed to require an insurance policy to:

(1) Provide coverage for any additional drugs not otherwise required by law;

(2) Implement specific utilization management techniques, such as prior authorization or step therapy; or

(3) Cease use of tiered cost-sharing structures, including those strategies used to incentivize use of preventive services, disease management, and low-cost treatment options.

(e) Nothing in this section shall be construed to require a pharmacist to substitute a drug without the consent of the prescribing physician.

(f) Nothing contained in any other provision of law or rule shall preclude an insurance policy subject to this chapter from requiring specialty drugs to be obtained through a designated pharmacy or other source of those drugs.

(g) The commissioner may adopt rules regarding the enforcement processes for this section.

(h) The terms "class of drugs", "coinsurance", "commissioner", "copayment", "non-preferred drug", "preferred drug", "specialty drug", "specialty drug formulary", and "specialty drug tier" shall have the same respective meanings as in section 431:10A‑A."

SECTION 4. 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-   Specialty tier prescription coverage. (a) All individual and group hospital and medical service corporation contracts that provide coverage for prescription drugs and use a specialty drug tier shall ensure that any required copayment or coinsurance applicable to specialty drugs on a specialty tier does not exceed $150 per month for each specialty drug, up to a thirty day supply of any single drug.

(b) All individual and group hospital and medical service corporation contracts that provide coverage for prescription drugs and use a specialty drug formulary shall implement an exceptions process that allows members to request an exception to the formulary. Under this type of exception, a non-formulary specialty drug may be deemed covered under the formulary if the prescribing physician determines that the formulary drug for treatment of the same condition would not be as effective for the member, would have adverse effects for the member, or both. If an insured is denied an exception, the insured may pursue an internal appeal pursuant to section 432E-5 and an external review pursuant to section 432E-34.

(c) All individual and group hospital and medical service corporation contracts that provide coverage for prescription drugs shall be prohibited from placing all drugs in a given class of drugs on a specialty tier.

(d) Nothing in this section shall be construed to require a contract to:

(1) Provide coverage for any additional drugs not otherwise required by law;

(2) Implement specific utilization management techniques, such as prior authorization or step therapy; or

(3) Cease use of tiered cost-sharing structures, including those strategies used to incentivize use of preventive services, disease management, and low-cost treatment options.

(e) Nothing in this section shall be construed to require a pharmacist to substitute a drug without the consent of the prescribing physician.

(f) Nothing contained in any other provision of law or rule shall preclude a contract subject to this chapter from requiring specialty drugs to be obtained through a designated pharmacy or other source of those drugs.

(g) The commissioner may adopt rules regarding the enforcement processes for this section.

(h) The terms "class of drugs", "coinsurance", "commissioner", "copayment", "non-preferred drug", "preferred drug", "specialty drug", "specialty drug formulary", and "specialty drug tier" shall have the same respective meanings as in section 431:10A‑A."

SECTION 5. Chapter 432D, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:

"432D- Specialty tier prescription coverage. (a) All policies, contracts, plans, or agreements issued in the State by health maintenance organizations pursuant to this chapter that provide coverage for prescription drugs and use a specialty drug tier shall ensure that any required copayment or coinsurance applicable to specialty drugs on a specialty drug tier does not exceed $150 per month for each specialty drug, up to a thirty day supply of any single drug.

(b) All policies, contracts, plans, or agreements issued in the State by health maintenance organizations pursuant to this chapter that provide coverage for prescription drugs and use a specialty drug formulary shall implement an exceptions process that allows insureds to request an exception to the formulary. Under this type of exception, a non-formulary specialty drug may be deemed covered under the formulary if the prescribing physician determines that the formulary drug for treatment of the same condition would not be as effective for the insured, would have adverse effects for the insured, or both. If an insured is denied an exception, the insured may pursue an internal appeal pursuant to section 432E-5 and an external review pursuant to section 432E-34.

(c) All policies, contracts, plans, or agreements issued in the State by health maintenance organizations pursuant to this chapter that provide coverage for prescription drugs shall be prohibited from placing all drugs in a given class of drugs on a specialty drug tier.

(d) Nothing in this section shall be construed to require a policy, contract, plan, or agreement to:

(1) Provide coverage for any additional drugs not otherwise required by law;

(2) Implement specific utilization management techniques, such as prior authorization or step therapy; or

(3) Cease use of tiered cost-sharing structures, including those strategies used to incentivize use of preventive services, disease management, and low-cost treatment options.

(e) Nothing in this section shall be construed to require a pharmacist to substitute a drug without the consent of the prescribing physician.

(f) Nothing contained in any other provision of law or rule shall preclude a policy, contract, plan, or agreement subject to this chapter from requiring specialty drugs to be obtained through a designated pharmacy or other source of those drugs.

(g) The commissioner may adopt rules regarding the enforcement processes for this section.

(h) The terms "class of drugs", "coinsurance", "commissioner", "copayment", "non-preferred drug", "preferred drug", "specialty drug", "specialty drug formulary", and "specialty drug tier" shall have the same respective meanings as in section 431:10A‑A."

SECTION 6. In codifying the new sections added by sections 2 and 3 and referenced in sections 3, 4, and 5 of this Act, the revisor of statutes shall substitute appropriate section numbers for the letters used in designating the new sections in this Act.

SECTION 7. New statutory material is underscored.

SECTION 8. This Act shall take effect on July 1, 2021; provided that this Act shall apply to all health plan contracts issued or renewed in this State on or after January 1, 2022.

 

INTRODUCED BY:

_____________________________

 

 


 


 

Report Title:

Specialty Tier Prescription Coverage; Specialty Drugs; Health Plan

 

 

Description:

Imposes dollar limits on specialty tiers in order to protect patients from unaffordable coinsurance or copayment amounts. Limits patients' coinsurance or copayment fees for specialty tier drugs to $150 per month for up to a thirty-day period supply. Allow patients to request an exception to obtain a specialty drug that would not otherwise be available on a health plan formulary.

 

 

 

The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.