Healthcare (Prescription Drugs)

Health insurance; carrier contracts; required provisions regarding prior authorization for prescription drugs. Amends existing required provisions for health carrier contracts related to prior authorizations for prescription drugs. Current law requires that if prior authorization is approved for prescription drugs and such prescription drugs have been scheduled, provided, or delivered to the patient consistent with the authorization, health carriers may not revoke, limit, condition, modify, or restrict that authorization except in certain circumstances. The bill requires this limitation on carriers to apply for the duration of the authorization, which the bill requires to be a minimum of six months for initial authorizations and a minimum of 12 months for continued authorizations. The bill adds circumstances under which a prior authorization may be revoked, limited, conditioned, modified, or restricted by a carrier, including (i) a final action by the U.S. Food and Drug Administration, other regulatory agencies, or the manufacturer communicating a patient efficacy issue that would affect the authorization and (ii) when additional safety and efficacy monitoring is clinically appropriate or recommended by the U.S. Food and Drug Administration, other regulatory agencies, or the manufacturer.

Health insurance; requirements for certain opioid antagonists. Requires each health insurer, corporation providing health care subscription plans, and health maintenance organization whose policy, contract, or plan includes coverage for prescription drugs to include coverage for at least one opioid antagonist used for overdose reversal dispensed pursuant to an oral, written, or standing order of a prescriber and ensure that cost-sharing for at least one opioid antagonist used for overdose reversal is included on the lowest cost tier of the insurer's, corporation's, or health maintenance organization's prescription drug formulary. The bill provides that such coverage shall be exempt from any prior authorization or step therapy requirement on coverage of benefits. As introduced, this bill was a recommendation of the Joint Commission on Health Care. This bill is identical to HB 795.

Therapeutic interchange and adaptation. Authorizes pharmacists to perform therapeutic interchanges by substituting a drug with another drug in the same therapeutic class when such substitution lowers the cost or is cost-neutral to the patient or the prescribed drug is in a drug shortage and the substitution conforms to Board of Pharmacy regulations. The bill directs the Board of Pharmacy to determine which therapeutic classes of drugs shall be eligible for therapeutic interchange and which classes shall be prohibited. The bill also authorizes pharmacists to adapt prescriptions by changing the dosage form or quantity of a medication or by completing missing information on a prescription when there is evidence to support such change.

Board of Pharmacy; regulation of psilocybin. Directs the Board of Pharmacy to reschedule psilocybin consistent with federal scheduling upon approval by the U.S. Food and Drug Administration of a formulation of psilocybin designed to be administered by a health care professional in a health care setting. This bill is identical to HB 1347.

Prescription Drug Affordability Advisory Panel established; maximum fair price; annual reports; civil penalties. Directs the Secretary of Health and Human Resources to establish the Prescription Drug Affordability Advisory Panel to conduct data analyses, develop policy recommendations, and identify implementation barriers related to strategies to improve prescription drug affordability, enhance price transparency, and strengthen data collection practices for prescription drugs across public and private payers. The bill requires the Panel to (i) report annually on prescription drug pricing trends and any policy recommendations on legislation to improve prescription drug affordability and (ii) provide quarterly updates on prescription drug pricing trends. The bill requires each pharmacy benefits manager to provide to the Panel, upon request, certain information relating to the dispensation of a referenced drug, as defined in the bill.The bill prohibits prescription drug manufacturers or wholesale distributors permitted or licensed in the Commonwealth from accepting payment at an amount higher than the maximum fair price established by the U.S. Secretary of Health and Human Services pursuant to federal law for the sale of a referenced drug intended for use by individuals in the Commonwealth. Under the bill, an entity that violates such prohibition is subject to a civil penalty of $10,000 per violation. The bill also prohibits a manufacturer subject to its provisions from removing a referenced drug from sale distribution in the Commonwealth for the purpose of avoiding the impact of the bill's rate limitations without providing certain prior notice. Under the bill, a manufacturer that violates such prohibition on removing a referenced drug without the required notice is subject to a civil penalty equal to the greater of $100,000 or the total amount of annual savings for the referenced drug, as determined by the Board of Pharmacy. This bill is identical to SB 271.

Health insurance; limit on cost-sharing payments for prescription drugs under certain plans. Requires each carrier that offers a health plan in either the individual or small group market to ensure that at least one health plan in each of the bronze, silver, gold, and platinum levels of coverage in each rating area in the individual and small group market conform with the following: (i) a plan that offers a platinum level of coverage shall limit a person's cost-sharing payment for prescription drugs covered under the plan to an amount that does not exceed $150 per 30-day supply of the prescription drug; (ii) a plan that offers a gold level of coverage shall limit a person's cost-sharing payment for prescription drugs covered under the plan to an amount that does not exceed $200 per 30-day supply of the prescription drug; (iii) a plan that offers a silver level of coverage shall limit a person's cost-sharing payment for prescription drugs covered under the plan to an amount that does not exceed $250 per 30-day supply of the prescription drug; and (iv) a plan that offers a bronze level of coverage shall limit a person's cost-sharing payment for prescription drugs covered under the plan to an amount that does not exceed $300 per 30-day supply of the prescription drug. The bill requires that any plans offered to meet its requirements are (a) clearly and appropriately named to aid the consumer or plan sponsor in the plan selection process and (b) marketed in the same manner as other plans offered by the carrier. The bill's provisions apply to any individual or group accident and sickness insurance policy, any individual or group accident and sickness subscription contract, and any health care plan for health care services delivered, issued for delivery, or renewed in the Commonwealth on or after January 1, 2028. This bill is identical to HB 625.

Health insurance; pharmacies; freedom of choice; delivery of prescription drugs; penalties. Prohibits an insurer, health maintenance organization, corporation providing preferred provider subscription contracts, or pharmacy benefits manager from imposing upon any person receiving pharmaceutical benefits any policy or practice requiring or incentivizing certain provisions relating to the delivery of prescription drugs. A violation of the bill's provisions constitutes an unfair trade practice under existing law and is subject to injunctive, penalty, and enforcement provisions in existing law.

Prescription Drug Affordability Advisory Panel established; maximum fair price; annual reports; civil penalties. Directs the Secretary of Health and Human Resources to establish the Prescription Drug Affordability Advisory Panel to conduct data analyses, develop policy recommendations, and identify implementation barriers related to strategies to improve prescription drug affordability, enhance price transparency, and strengthen data collection practices for prescription drugs across public and private payers. The bill requires the Panel to (i) report annually on prescription drug pricing trends and any policy recommendations on legislation to improve prescription drug affordability and (ii) provide quarterly updates on prescription drug pricing trends. The bill requires each pharmacy benefits manager to provide to the Panel, upon request, certain information relating to the dispensation of a referenced drug, as defined in the bill.The bill prohibits prescription drug manufacturers or wholesale distributors permitted or licensed in the Commonwealth from accepting payment at an amount higher than the maximum fair price established by the U.S. Secretary of Health and Human Services pursuant to federal law for the sale of a referenced drug intended for use by individuals in the Commonwealth. Under the bill, an entity that violates such prohibition is subject to a civil penalty of $10,000 per violation. The bill also prohibits a manufacturer subject to its provisions from removing a referenced drug from sale distribution in the Commonwealth for the purpose of avoiding the impact of the bill's rate limitations without providing certain prior notice. Under the bill, a manufacturer that violates such prohibition on removing a referenced drug without the required notice is subject to a civil penalty equal to the greater of $100,000 or the total amount of annual savings for the referenced drug, as determined by the Board of Pharmacy. This bill is identical to HB 483.

Health insurance; treatment of cancer and certain diseases; coverage of certain medications. Requires an insurer, corporation providing preferred provider subscription contracts, or health maintenance organization that provides coverage for drugs approved by the Food and Drug Administration and prescribed for the treatment of cancer or diseases of the blood to allow, at the patient's direction, (i) provider-administered drugs for such treatment to be dispensed by an in-network treating provider consistent with a provider agreement; (ii) provider-administered drugs for such treatment to be dispensed by an in-network treating provider when there is a documented delay of at least three days in the delivery of a medication from the designated specialty pharmacy; and (iii) self-administered drugs for such treatment to be sent to the pharmacy of the patient's choosing.

Health insurance; coverage for contraceptive drugs and devices. Requires health insurance carriers to provide coverage, under any health insurance contract, policy, or plan that includes coverage for prescription drugs on an outpatient basis, for contraceptive drugs and contraceptive devices approved by the U.S. Food and Drug Administration, including those available over-the-counter. The bill prohibits a health insurance carrier from imposing upon any person receiving prescription contraceptive benefits pursuant to the provisions of the bill any copayment, coinsurance payment, or fee, except in certain circumstances. Additionally, the bill requires any health benefit plan that provides coverage for hormonal contraceptives to provide point-of-sale coverage without cost-sharing at in-network pharmacies for hormonal contraceptives available over-the-counter. This bill is identical to HB 1182.