Bill > H4491

This bill addresses non-medical switching in health insurance prescription drug coverage, prohibiting health carriers from making restrictive changes to their formularies that would force patients to switch from a currently prescribed medication without medical justification. Specifically, the bill prevents health carriers from limiting or excluding coverage for a prescription drug if the patient is medically stable on that drug, as determined by their healthcare professional, and the drug was previously approved for coverage. The bill establishes a detailed coverage exemption determination process that requires health carriers to provide a clear and accessible method for patients and healthcare professionals to request continued coverage, with response times of 72 hours (or 24 hours in urgent circumstances). If a health carrier does not respond within the specified timeframe, the coverage exemption is automatically granted. The bill also ensures that patients can appeal any denial of coverage exemption and have the right to external review. Health carriers are still allowed to make some formulary changes, such as adding drugs or removing drugs that are no longer manufactured, but cannot arbitrarily switch patients to less expensive medications. The provisions will apply to health benefit plans delivered, issued, or renewed in the state on or after January 1, 2026, and the insurance commissioner is authorized to enforce compliance with these new regulations.

Budget and Finance, Health and Social Services

Joint Committee on Financial Services (Joint)

https://malegislature.gov/Bills/194/H4491