Amendment #34, as changed to H.4743

Amendment #34 to H4743

Emergency Opioid Antagonists

Mr. Donato of Medford moves to amend the bill in paragraphs (a) and (b) of Section 1 and replace with the following new language:

Section 17T. (a) Any coverage offered by the commission to an active or retired employee of the commonwealth insured under the group insurance commission shall provide coverage for prescribed or dispensed emergency opioid antagonists, as defined in section 19B of chapter 94C, which shall be deemed medically necessary and shall not require prior authorization, provided however, that prior authorization may be required if the prescription exceeds two emergency opioid antagonist kits; provided, however, that a prescription from a health care practitioner shall not be required for coverage of emergency opioid antagonists. An emergency opioid antagonist shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.

(b) The commission shall provide coverage for an emergency opioid antagonist as a medical benefit when dispensed by the health care facility in which the opioid antagonist was prescribed, provided that the rate to be reimbursed under the medical benefit shall not exceed the commission’s average in-network pharmacy benefit rate, and shall provide coverage as a pharmacy benefit for an opioid antagonist dispensed by a pharmacist, including an opioid antagonist dispensed pursuant to section 19B of chapter 94C.

And further amended by striking paragraphs (a) and (b) of Section 11 and replace with the following new language:

Section 10R. The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan shall provide coverage for prescribed or dispensed emergency opioid antagonists, as defined in section 19B of chapter 94C, which shall be deemed medically necessary and shall not require prior authorization, provided however, that prior authorization may be required if the prescription exceeds two emergency opioid antagonist kits; provided, however, that a prescription from a health care practitioner shall not be required for emergency coverage of opioid antagonists. An emergency opioid antagonist shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.

(b) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators shall provide coverage for an emergency opioid antagonist as a medical benefit when dispensed by the health care facility in which the opioid antagonist was prescribed, provided that the rate to be reimbursed under the medical benefit shall not exceed the division’s average in-network pharmacy benefit rate, and shall provide coverage as a pharmacy benefit for an opioid antagonist dispensed by a pharmacist, including an opioid antagonist dispensed pursuant to section 19B of chapter 94C.

And further amended by striking paragraphs (a) and (b) of Section 14 and replace with the following new language:

Section 47VV. Any policy, contract, agreement, plan or certificate of insurance issued, delivered or renewed within the commonwealth, which is considered creditable coverage under section 1 of chapter 111M, shall provide coverage for prescribed or dispensed opioid antagonists, as defined in section 19B of chapter 94C, which shall be deemed medically necessary and shall not require prior authorization, provided however, that prior authorization may be required if the prescription exceeds two emergency opioid antagonist kits; provided, however, that a prescription from a health care practitioner shall not be required for coverage of emergency opioid antagonists. An emergency opioid antagonist shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.

(b) The policy, contract, agreement, plan or certificate of insurance shall provide coverage for an emergency opioid antagonist as a medical benefit when dispensed by the health care facility in which the opioid antagonist was prescribed, provided that the rate to be reimbursed under the medical benefit shall not exceed the carrier’s average in-network pharmacy benefit rate, and shall provide coverage as a pharmacy benefit for an opioid antagonist dispensed by a pharmacist, including an opioid antagonist dispensed pursuant to section 19B of chapter 94C.

And further amended by striking paragraphs (a) and (b) of Section 16 and replace with the following new language:

Section 8WW. Any contract between a subscriber and the corporation under an individual or group hospital service plan that is delivered, issued or renewed within the commonwealth shall provide coverage for prescribed or dispensed emergency opioid antagonists, as defined in section 19B of chapter 94C, which shall be deemed medically necessary and shall not require prior authorization, provided however, that prior authorization may be required if the prescription exceeds two emergency opioid antagonist kits; provided, however, that a prescription from a health care practitioner shall not be required for coverage of emergency opioid antagonists. An emergency opioid antagonist shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.

(b) Such contract shall provide coverage for an emergency opioid antagonist as a medical benefit when dispensed by the health care facility in which the opioid antagonist was prescribed, provided that the rate to be reimbursed under the medical benefit shall not exceed the carrier’s average in-network pharmacy benefit rate, and shall provide coverage as a pharmacy benefit for an opioid antagonist dispensed by a pharmacist, including an opioid antagonist dispensed pursuant to section 19B of chapter 94C.

And further amended by striking paragraphs (a) and (b) of Section 17 and replace with the following new language:

Section 4WW. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth, shall provide coverage for prescribed or dispensed emergency opioid antagonists, as defined in section 19B of chapter 94C, which shall be deemed medically necessary and shall not require prior authorization, provided however, that prior authorization may be required if the prescription exceeds two emergency opioid antagonist kits; provided, however, that a prescription from a health care practitioner shall not be required for coverage of emergency opioid antagonists. An emergency opioid antagonist shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.

And further amended by striking paragraphs (a) and (b) of Section 18 and replace with the following new language:

Section 4OO. An individual or group health maintenance contract that is issued or renewed within or without the commonwealth shall provide coverage for prescribed or dispensed emergency opioid antagonists, as defined in section 19B of chapter 94C, which shall be deemed medically necessary and shall not require prior authorization provided however, that prior authorization may be required if the prescription exceeds two emergency opioid antagonist kits; provided, however, that a prescription from a health care practitioner shall not be required for coverage of emergency opioid antagonists. An emergency opioid antagonist shall not be subject to any deductible, coinsurance, copayments or out-of-pocket limits; provided, however, that cost-sharing shall be required if the applicable plan is governed by the federal Internal Revenue Code and would lose its tax-exempt status as a result of the prohibition on cost-sharing for this service.

(b) The individual or group health maintenance contract shall provide coverage for an emergency opioid antagonist as a medical benefit when dispensed by the health care facility in which the opioid antagonist was prescribed, provided that the rate to be reimbursed under the medical benefit shall not exceed the carrier’s average in-network pharmacy benefit rate, and shall provide coverage as a pharmacy benefit for an opioid antagonist dispensed by a pharmacist, including an opioid antagonist dispensed pursuant to section 19B of chapter 94C.