Bill > A4595

This bill requires health insurers, including hospital service corporations, medical service corporations, health service corporations, individual and group health insurance policies, health benefits plans, and health maintenance organizations, to limit a patient's out-of-pocket costs for prescription drugs to no more than $100 per month for a 30-day supply of any single drug, with exceptions for "bronze level" coverage which has a $200 monthly limit, and catastrophic plans which are exempt. These limits apply regardless of whether a deductible has been met, except for high-deductible health plans where prescription drug benefits only begin after the deductible is satisfied, after which the monthly limits apply. Additionally, insurers must establish an exceptions process allowing patients to request coverage for a non-formulary drug if their doctor determines the formulary alternative would be ineffective or cause adverse effects; denials of these exceptions are considered adverse determinations subject to appeal. The State Health Benefits Commission and the School Employees' Health Benefits Commission are also mandated to ensure their contracts adhere to these same prescription drug cost limits and exceptions process.