Bill Text: OH SB364 | 2013-2014 | 130th General Assembly | Introduced
Bill Title: To limit the out-of-pocket cost to an individual covered by a health plan for drugs used to treat rare diseases.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Introduced - Dead) 2014-09-22 - To Insurance & Financial Institutions [SB364 Detail]
Download: Ohio-2013-SB364-Introduced.html
|
|
Senator Cafaro
Cosponsor:
Senator Turner
| To amend section 1739.05 and to enact sections | 1 |
| 1751.691 and 3923.851 of the Revised Code to limit | 2 |
| the out-of-pocket cost to an individual covered by | 3 |
| a health plan for drugs used to treat rare | 4 |
| diseases. | 5 |
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:
| Section 1. That section 1739.05 be amended and sections | 6 |
| 1751.691 and 3923.851 of the Revised Code be enacted to read as | 7 |
| follows: | 8 |
| Sec. 1739.05. (A) A multiple employer welfare arrangement | 9 |
| that is created pursuant to sections 1739.01 to 1739.22 of the | 10 |
| Revised Code and that operates a group self-insurance program may | 11 |
| be established only if any of the following applies: | 12 |
| (1) The arrangement has and maintains a minimum enrollment of | 13 |
| three hundred employees of two or more employers. | 14 |
| (2) The arrangement has and maintains a minimum enrollment of | 15 |
| three hundred self-employed individuals. | 16 |
| (3) The arrangement has and maintains a minimum enrollment of | 17 |
| three hundred employees or self-employed individuals in any | 18 |
| combination of divisions (A)(1) and (2) of this section. | 19 |
| (B) A multiple employer welfare arrangement that is created | 20 |
| pursuant to sections 1739.01 to 1739.22 of the Revised Code and | 21 |
| that operates a group self-insurance program shall comply with all | 22 |
| laws applicable to self-funded programs in this state, including | 23 |
| sections 3901.04, 3901.041, 3901.19 to 3901.26, 3901.38, 3901.381 | 24 |
| to 3901.3814, 3901.40, 3901.45, 3901.46, 3902.01 to 3902.14, | 25 |
| 3923.24, 3923.282, 3923.30, 3923.301, 3923.38, 3923.581, 3923.63, | 26 |
| 3923.80, 3923.85, 3923.851, 3924.031, 3924.032, and 3924.27 of the | 27 |
| Revised Code. | 28 |
| (C) A multiple employer welfare arrangement created pursuant | 29 |
| to sections 1739.01 to 1739.22 of the Revised Code shall solicit | 30 |
| enrollments only through agents or solicitors licensed pursuant to | 31 |
| Chapter 3905. of the Revised Code to sell or solicit sickness and | 32 |
| accident insurance. | 33 |
| (D) A multiple employer welfare arrangement created pursuant | 34 |
| to sections 1739.01 to 1739.22 of the Revised Code shall provide | 35 |
| benefits only to individuals who are members, employees of | 36 |
| members, or the dependents of members or employees, or are | 37 |
| eligible for continuation of coverage under section 1751.53 or | 38 |
| 3923.38 of the Revised Code or under Title X of the "Consolidated | 39 |
| Omnibus Budget Reconciliation Act of 1985," 100 Stat. 227, 29 | 40 |
| U.S.C.A. 1161, as amended. | 41 |
| Sec. 1751.691. (A) As used in this section: | 42 |
| (1) "Cost sharing" has the same meaning as in section 1751.69 | 43 |
| of the Revised Code. | 44 |
| (2) "Preferred drug formulary" means any list that groups | 45 |
| drugs covered by an individual or group health insuring | 46 |
| corporation policy, contract, or agreement into tiers and for | 47 |
| which a cost-sharing requirement is established for each tier. | 48 |
| (3) "Rare disease or condition" has the same meaning as in 21 | 49 |
| U.S.C. 360bb(a)(2). | 50 |
| (4) "Specialty drug" means a prescription drug that meets all | 51 |
| of the following: | 52 |
| (a) The drug is prescribed for a person who has been | 53 |
| diagnosed with either of the following: | 54 |
| (i) A physical, behavioral, or developmental condition that | 55 |
| may or may not have any known cure and that is progressive, | 56 |
| debilitating, or fatal if left untreated or under-treated, | 57 |
| including multiple sclerosis, hepatitis C, and rheumatoid | 58 |
| arthritis; | 59 |
| (ii) A rare disease or condition. | 60 |
| (b) The drug is not stocked at a majority of retail | 61 |
| pharmacies. | 62 |
| (c) The drug has at least one of the following | 63 |
| characteristics: | 64 |
| (i) It is an oral, injectable, or infusible drug. | 65 |
| (ii) It has unique storage or shipment requirements, such as | 66 |
| refrigeration. | 67 |
| (iii) Patients receiving the drug require education and | 68 |
| support beyond traditional dispensing activities. | 69 |
| (5) "Specialty drug tier" means a tier of a preferred drug | 70 |
| formulary that imposes cost-sharing requirements for specialty | 71 |
| drugs that are higher than for nonspecialty drugs. | 72 |
| (B) Notwithstanding section 3901.71 of the Revised Code, an | 73 |
| individual or group health insuring corporation policy, contract, | 74 |
| or agreement providing prescription drug services that is | 75 |
| delivered, issued for delivery, or renewed in this state shall | 76 |
| comply with both of the following: | 77 |
| (1) The policy, contract, or agreement shall not impose cost | 78 |
| sharing for specialty drugs of more than one hundred fifty dollars | 79 |
| for a one-month supply. | 80 |
| (2)(a) The policy, contract, or agreement shall establish a | 81 |
| process by which a covered individual may request that a specialty | 82 |
| drug that is not listed on a preferred drug formulary may be | 83 |
| covered and subject to cost-sharing requirements as if it were | 84 |
| listed on the formulary. | 85 |
| (b) The denial of such a request shall be treated as an | 86 |
| adverse benefit determination, subject to internal appeal and | 87 |
| external review under Chapter 3922. of the Revised Code. | 88 |
| (C) Nothing in this section shall be interpreted as requiring | 89 |
| a policy, contract, or agreement to do any of the following: | 90 |
| (1) Provide coverage for any additional drugs not otherwise | 91 |
| required by law; | 92 |
| (2) Implement specific utilization management techniques, | 93 |
| such as prior authorization or step therapy; | 94 |
| (3) Stop the use of any cost-sharing requirements, policies, | 95 |
| or procedures that are not otherwise prohibited under this section | 96 |
| or any other section of law, including those strategies used to | 97 |
| incentivize the use of preventative services, disease management, | 98 |
| and low-cost treatment options. | 99 |
| (D) A policy, contract, or agreement shall not place all | 100 |
| drugs in a given class on a specialty tier. | 101 |
| (E) Nothing in this section shall be interpreted as | 102 |
| prohibiting a policy, contract, or agreement from requiring that | 103 |
| specialty drugs be obtained through a designated pharmacy or other | 104 |
| source of such drugs. | 105 |
| (F) Nothing in this section shall be interpreted as requiring | 106 |
| a pharmacist to substitute a drug without the consent of the | 107 |
| prescribing physician. | 108 |
| Sec. 3923.851. (A) As used in this section: | 109 |
| (1) "Cost sharing" has the same meaning as in section 1751.69 | 110 |
| of the Revised Code. | 111 |
| (2) "Preferred drug formulary" means any list that groups | 112 |
| drugs covered by an individual or group policy of sickness and | 113 |
| accident insurance or a public employee benefit plan into tiers | 114 |
| and for which a cost-sharing requirement is established for each | 115 |
| tier. | 116 |
| (3) "Rare disease or condition" has the same meaning as in 21 | 117 |
| U.S.C. 360bb(a)(2). | 118 |
| (4) "Specialty drug" means a prescription drug that meets all | 119 |
| of the following: | 120 |
| (a) The drug is prescribed for a person who has been | 121 |
| diagnosed with either of the following: | 122 |
| (i) A physical, behavioral, or developmental condition that | 123 |
| may or may not have any known cure and that is progressive, | 124 |
| debilitating, or fatal if left untreated or under-treated, | 125 |
| including multiple sclerosis, hepatitis C, and rheumatoid | 126 |
| arthritis; | 127 |
| (ii) A rare disease or condition. | 128 |
| (b) The drug is not stocked at a majority of retail | 129 |
| pharmacies. | 130 |
| (c) The drug has at least one of the following | 131 |
| characteristics: | 132 |
| (i) It is an oral, injectable, or infusible drug. | 133 |
| (ii) It has unique storage or shipment requirements, such as | 134 |
| refrigeration. | 135 |
| (iii) Patients receiving the drug require education and | 136 |
| support beyond traditional dispensing activities. | 137 |
| (B) Notwithstanding section 3901.71 of the Revised Code, an | 138 |
| individual or group policy of sickness and accident insurance that | 139 |
| is delivered, issued for delivery, or renewed in this state and a | 140 |
| public employee benefit plan that is established or modified in | 141 |
| this state, that provides prescription drug services shall comply | 142 |
| with both of the following: | 143 |
| (1) The policy or plan shall not impose cost sharing for | 144 |
| specialty drugs of more than one hundred fifty dollars for a | 145 |
| one-month supply. | 146 |
| (2)(a) The policy or plan shall establish a process by which | 147 |
| a covered individual may request that a specialty drug that is not | 148 |
| listed on a preferred drug formulary may be covered and subject to | 149 |
| cost-sharing requirements as if it were listed on the formulary. | 150 |
| (b) The denial of such a request shall be treated as an | 151 |
| adverse benefit determination, subject to internal appeal and | 152 |
| external review under Chapter 3922. of the Revised Code. | 153 |
| (C) Nothing in this section shall be interpreted as requiring | 154 |
| a policy or plan to do any of the following: | 155 |
| (1) Provide coverage for any additional drugs not otherwise | 156 |
| required by law; | 157 |
| (2) Implement specific utilization management techniques, | 158 |
| such as prior authorization or step therapy; | 159 |
| (3) Stop the use of any cost-sharing requirements, policies, | 160 |
| or procedures that are not otherwise prohibited under this section | 161 |
| or any other section of law, including those strategies used to | 162 |
| incentivize the use of preventative services, disease management, | 163 |
| and low-cost treatment options. | 164 |
| (D) A policy or plan shall not place all drugs in a given | 165 |
| class on a specialty tier. | 166 |
| (E) Nothing in this section shall be interpreted as | 167 |
| prohibiting a policy or plan from requiring that specialty drugs | 168 |
| be obtained through a designated pharmacy or other source of such | 169 |
| drugs. | 170 |
| (F) Nothing in this section shall be interpreted as requiring | 171 |
| a pharmacist to substitute a drug without the consent of the | 172 |
| prescribing physician. | 173 |
| Section 2. That existing section 1739.05 of the Revised Code | 174 |
| is hereby repealed. | 175 |
| Section 3. Sections 1739.05 and 1751.691 of the Revised Code, | 176 |
| as amended or enacted by this act, apply only to policies, | 177 |
| contracts, agreements, and arrangements that are delivered, issued | 178 |
| for delivery, or renewed in this state on or after January 1, | 179 |
| 2015. Section 3923.851 of the Revised Code, as enacted by this | 180 |
| act, applies only to policies of sickness and accident insurance | 181 |
| delivered, issued for delivery, or renewed in this state, and | 182 |
| public employee benefit plans that are established or modified in | 183 |
| this state, on or after January 1, 2015. | 184 |
