Bill > HB1461

This bill modifies existing law to prevent certain health insurers, nonprofit health service plans, and health maintenance organizations from denying coverage for specialty drugs used to treat rheumatologic conditions, which are complex diseases affecting joints and connective tissues. Specifically, it expands the circumstances under which these entities must cover such drugs when administered or dispensed by an in-network provider of rheumatology services who also adheres to state regulations for specialty drugs. The bill clarifies that coverage cannot be excluded if the specialty drug is auto-injected, an oral targeted immune modulator, or an oral medication requiring complex dosing or used alongside other infusion therapies. It also addresses reimbursement rates for these drugs, requiring them to be agreed upon by the provider and insurer and billed at a non-hospital level of care, with a cap on reimbursement rates unless otherwise negotiated. The bill does not prevent insurers from denying coverage if a drug fails to meet medical necessity criteria and clarifies that it does not override the authority of the Health Services Cost Review Commission to set rates for drugs administered in regulated hospital settings. These changes will apply to policies and plans issued, delivered, or renewed on or after January 1, 2027.