Bill > S3142

This bill mandates that health insurers, including hospital service corporations, medical service corporations, health service corporations, individual and group health insurance policies, individual and small employer health benefits plans, and health maintenance organizations (HMOs), must 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 plans which have 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 are only covered after the deductible is satisfied, at which point the monthly cost-sharing limits then apply. Furthermore, insurers must establish an exceptions process allowing patients to request coverage for drugs not on their formulary if their doctor determines a formulary drug would be less effective or cause adverse effects, and any denial of such an exception must be treated as an adverse determination subject to appeal. The State Health Benefits Commission and the School Employees' Health Benefits Commission are also required to ensure their contracts for prescription drug benefits adhere to these same cost-sharing limits and exceptions process.