Amendment ID: S2499-6
Amendment 6
Continuity of Care/Exception Amendment
Mr. Kennedy moves that the proposed new draft be amended by striking paragraph (f) in SECTION 41 in its entirety and inserting in place thereof the following:-
(f) a member and their prescribing health care provider shall have access to a clear, readily accessible and convenient process to request to use a different brand name drug or generic drug of the same pharmacological class in place of a brand name drug or generic drug. Such request shall be granted if any of the following conditions are satisfied: (i) the brand name drugs and generic drugs selected pursuant to subsection (b) are contraindicated or will likely cause an adverse reaction in or physical or mental harm to the member; (ii) the brand name drugs and generic drugs selected pursuant to subsection (b) are expected to be ineffective based on the known clinical characteristics of the member and the known characteristics of the prescription drug regimen; (iii) the member or prescribing health care provider: (A) has provided documentation to the commission establishing that the member has previously tried the brand name drugs and generic drugs selected pursuant to subsection (b),while covered by a previous health insurance carrier or a health benefit plan; and (B) such prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event; (iv) the member or prescribing health care provider has provided documentation to the carrier establishing that the member: (A) is stable on a prescription drug prescribed by the health care provider; and (B) switching drugs will likely cause an adverse reaction in or physical or mental harm to the member.
And to further amend said SECTION 41 by striking paragraph (g) in its entirety and inserting in its place the following: -
(g) The commission shall implement a continuity of coverage policy to apply to members that are new to the commission to ensure that the member does not experience any delay in accessing a United States Food and Drug Administration-approved drug reimbursed through a pharmacy benefit that the member has already been prescribed and on which the member is stable, upon documentation by the member’s prescriber, and which was selected by the member’s previous payer as a drug subject to the cost sharing requirements set forth in paragraph (b) of this section; provided, however, that a carrier shall not apply any greater deductible, coinsurance, copayments or out-of-pocket limits than would otherwise apply to other drugs.
And to further amend said SECTION 41 by striking paragraph (h) in its entirety.
And to amend SECTION 44 of the bill by striking paragraph (f) in its entirety and inserting in place thereof the following:-
(f) a member and their prescribing health care provider shall have access to a clear, readily accessible and convenient process to request to use a different brand name drug or generic drug of the same pharmacological class in place of a brand name drug or generic drug. Such request shall be granted if any of the following conditions are satisfied: (i) the brand name drugs and generic drugs selected pursuant to subsection (b) are contraindicated or will likely cause an adverse reaction in or physical or mental harm to the member; (ii) the brand name drugs and generic drugs selected pursuant to subsection (b) are expected to be ineffective based on the known clinical characteristics of the member and the known characteristics of the prescription drug regimen; (iii) the member or prescribing health care provider: (A) has provided documentation to the division establishing that the member has previously tried the brand name drugs and generic drugs selected pursuant to subsection (b),while covered by a previous health insurance carrier or a health benefit plan; and (B) such prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event; (iv) the member or prescribing health care provider has provided documentation to the carrier establishing that the member: (A) is stable on a prescription drug prescribed by the health care provider; and (B) switching drugs will likely cause an adverse reaction in or physical or mental harm to the member.
And to further amend said SECTION 44 by striking paragraph (g) in its entirety and inserting in its place the following: -
(g) The division shall implement a continuity of coverage policy to apply to members that are new to the division to ensure that the member does not experience any delay in accessing a United States Food and Drug Administration-approved drug reimbursed through a pharmacy benefit that the member has already been prescribed and on which the member is stable, upon documentation by the member’s prescriber, and which was selected by the member’s previous payer as a drug subject to the cost sharing requirements set forth in paragraph (b) of this section; provided, however, that the division shall not apply any greater deductible, coinsurance, copayments or out-of-pocket limits than would otherwise apply to other drugs.
And to further amend said SECTION 44 by striking paragraph (h) in its entirety.
And to amend SECTION 45 of the bill by striking paragraph (f) in its entirety and inserting in place thereof the following:-
(f) a member and their prescribing health care provider shall have access to a clear, readily accessible and convenient process to request to use a different brand name drug or generic drug of the same pharmacological class in place of a brand name drug or generic drug. Such request shall be granted if any of the following conditions are satisfied: (i) the brand name drugs and generic drugs selected pursuant to subsection (b) are contraindicated or will likely cause an adverse reaction in or physical or mental harm to the member; (ii) the brand name drugs and generic drugs selected pursuant to subsection (b) are expected to be ineffective based on the known clinical characteristics of the member and the known characteristics of the prescription drug regimen; (iii) the member or prescribing health care provider: (A) has provided documentation to the carrier establishing that the member has previously tried the brand name drugs and generic drugs selected pursuant to subsection (b),while covered by a previous health insurance carrier or a health benefit plan; and (B) such prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event; (iv) the member or prescribing health care provider has provided documentation to the carrier establishing that the member: (A) is stable on a prescription drug prescribed by the health care provider; and (B) switching drugs will likely cause an adverse reaction in or physical or mental harm to the member.
And to further amend said SECTION 45 by striking paragraph (g) in its entirety and inserting in its place the following: -
(g) The carrier shall implement a continuity of coverage policy pursuant to chapter 254 of the acts of 2022 to apply to members that are new to the carrier to ensure that the member does not experience any delay in accessing a United States Food and Drug Administration-approved drug reimbursed through a pharmacy benefit that the member has already been prescribed and on which the member is stable, upon documentation by the member’s prescriber, and which was selected by the member’s previous payer as a drug subject to the cost sharing requirements set forth in paragraph (b) of this section; provided, however, that a carrier shall not apply any greater deductible, coinsurance, copayments or out-of-pocket limits than would otherwise apply to other drugs.
And to further amend said SECTION 45 by striking paragraph (h) in its entirety.
And to amend SECTION 47 of the bill by striking paragraph (f) in its entirety and inserting in place thereof the following:-
(f) a member and their prescribing health care provider shall have access to a clear, readily accessible and convenient process to request to use a different brand name drug or generic drug of the same pharmacological class in place of a brand name drug or generic drug. Such request shall be granted if any of the following conditions are satisfied: (i) the brand name drugs and generic drugs selected pursuant to subsection (b) are contraindicated or will likely cause an adverse reaction in or physical or mental harm to the member; (ii) the brand name drugs and generic drugs selected pursuant to subsection (b) are expected to be ineffective based on the known clinical characteristics of the member and the known characteristics of the prescription drug regimen; (iii) the member or prescribing health care provider: (A) has provided documentation to the carrier establishing that the member has previously tried the brand name drugs and generic drugs selected pursuant to subsection (b),while covered by a previous health insurance carrier or a health benefit plan; and (B) such prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event; (iv) the member or prescribing health care provider has provided documentation to the carrier establishing that the member: (A) is stable on a prescription drug prescribed by the health care provider; and (B) switching drugs will likely cause an adverse reaction in or physical or mental harm to the member.
And to further amend said SECTION 47 by striking paragraph (g) in its entirety and inserting in its place the following: -
(g) A carrier shall implement a continuity of coverage policy pursuant to chapter 254 of the acts of 2022 to apply to members that are new to the carrier to ensure that the member does not experience any delay in accessing a United States Food and Drug Administration-approved drug reimbursed through a pharmacy benefit that the member has already been prescribed and on which the member is stable, upon documentation by the member’s prescriber, and which was selected by the member’s previous payer as a drug subject to the cost sharing requirements set forth in paragraph (b) of this section; provided, however, that a carrier shall not apply any greater deductible, coinsurance, copayments or out-of-pocket limits than would otherwise apply to other drugs.
And to further amend said SECTION 47 by striking paragraph (h) in its entirety.
And to amend SECTION 48 of the bill by striking paragraph (f) in its entirety and inserting in place thereof the following:-
(f) a member and their prescribing health care provider shall have access to a clear, readily accessible and convenient process to request to use a different brand name drug or generic drug of the same pharmacological class in place of a brand name drug or generic drug. Such request shall be granted if any of the following conditions are satisfied: (i) the brand name drugs and generic drugs selected pursuant to subsection (b) are contraindicated or will likely cause an adverse reaction in or physical or mental harm to the member; (ii) the brand name drugs and generic drugs selected pursuant to subsection (b) are expected to be ineffective based on the known clinical characteristics of the member and the known characteristics of the prescription drug regimen; (iii) the member or prescribing health care provider: (A) has provided documentation to the division establishing that the member has previously tried the brand name drugs and generic drugs selected pursuant to subsection (b),while covered by a previous health insurance carrier or a health benefit plan; and (B) such prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event; (iv) the member or prescribing health care provider has provided documentation to the carrier establishing that the member: (A) is stable on a prescription drug prescribed by the health care provider; and (B) switching drugs will likely cause an adverse reaction in or physical or mental harm to the member.
And to further amend said SECTION 48 by striking paragraph (g) in its entirety and inserting in its place the following:-
(g) A carrier shall implement a continuity of coverage policy pursuant to chapter 254 of the acts of 2022 to apply to members that are new to the carrier to ensure that the member does not experience any delay in accessing a United States Food and Drug Administration-approved drug reimbursed through a pharmacy benefit that the member has already been prescribed and on which the member is stable, upon documentation by the member’s prescriber, and which was selected by the member’s previous payer as a drug subject to the cost sharing requirements set forth in paragraph (b) of this section; provided, however, that a carrier shall not apply any greater deductible, coinsurance, copayments or out-of-pocket limits than would otherwise apply to other drugs.
And to further amend said SECTION 48 by striking paragraph (h) in its entirety.
And to amend SECTION 52 of the bill by striking paragraph (f) in its entirety and inserting in place thereof the following:-
(f) a member and their prescribing health care provider shall have access to a clear, readily accessible and convenient process to request to use a different brand name drug or generic drug of the same pharmacological class in place of a brand name drug or generic drug. Such request shall be granted if any of the following conditions are satisfied: (i) the brand name drugs and generic drugs selected pursuant to subsection (b) are contraindicated or will likely cause an adverse reaction in or physical or mental harm to the member; (ii) the brand name drugs and generic drugs selected pursuant to subsection (b) are expected to be ineffective based on the known clinical characteristics of the member and the known characteristics of the prescription drug regimen; (iii) the member or prescribing health care provider: (A) has provided documentation to the carrier establishing that the member has previously tried the brand name drugs and generic drugs selected pursuant to subsection (b),while covered by a previous health insurance carrier or a health benefit plan; and (B) such prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event; (iv) the member or prescribing health care provider has provided documentation to the carrier establishing that the member: (A) is stable on a prescription drug prescribed by the health care provider; and (B) switching drugs will likely cause an adverse reaction in or physical or mental harm to the member.
And to further amend said SECTION 52 by striking paragraph (g) in its entirety and inserting in its place the following:-
(g) A carrier shall implement a continuity of coverage policy pursuant to chapter 254 of the acts of 2022 to apply to members that are new to the carrier to ensure that the member does not experience any delay in accessing a United States Food and Drug Administration-approved drug reimbursed through a pharmacy benefit that the member has already been prescribed and on which the member is stable, upon documentation by the member’s prescriber, and which was selected by the member’s previous payer as a drug subject to the cost sharing requirements set forth in paragraph (b) of this section; provided, however, that a carrier shall not apply any greater deductible, coinsurance, copayments or out-of-pocket limits than would otherwise apply to other drugs.
And to further amend said SECTION 52 by striking paragraph (h) in its entirety.