Senate
File
489
-
Introduced
SENATE
FILE
489
BY
COMMITTEE
ON
HUMAN
RESOURCES
(SUCCESSOR
TO
SF
292)
A
BILL
FOR
An
Act
relating
to
continuity
of
care
for
covered
persons
with
1
epilepsy,
and
nonmedical
switching
by
health
carriers,
2
health
benefit
plans,
and
utilization
review
organizations,
3
and
including
applicability
provisions.
4
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
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Section
1.
NEW
SECTION
.
514F.8
Continuity
of
care
——
1
nonmedical
switching.
2
1.
Definitions.
For
the
purpose
of
this
section:
3
a.
“Authorized
representative”
means
the
same
as
defined
in
4
section
514J.102.
5
b.
“Commissioner”
means
the
commissioner
of
insurance.
6
c.
“Cost
sharing”
means
any
coverage
limit,
copayment,
7
coinsurance,
deductible,
or
other
out-of-pocket
expense
8
requirement.
9
d.
“Coverage
exemption”
means
a
determination
made
by
a
10
health
carrier,
health
benefit
plan,
or
utilization
review
11
organization
to
cover
a
prescription
drug
that
is
otherwise
12
excluded
from
coverage.
13
e.
“Coverage
exemption
determination”
means
a
determination
14
made
by
a
health
carrier,
health
benefit
plan,
or
utilization
15
review
organization
whether
to
cover
a
prescription
drug
that
16
is
otherwise
excluded
from
coverage.
17
f.
“Covered
person”
means
a
policyholder,
subscriber,
18
enrollee,
or
other
individual
participating
in
a
health
benefit
19
plan
who
has
been
diagnosed
with
epilepsy.
20
g.
“Discontinued
health
benefit
plan”
means
a
covered
21
person’s
existing
health
benefit
plan
that
is
discontinued
by
a
22
health
carrier
during
open
enrollment
for
the
next
plan
year.
23
h.
“Formulary”
means
a
complete
list
of
prescription
drugs
24
eligible
for
coverage
under
a
health
benefit
plan.
25
i.
“Health
benefit
plan”
means
the
same
as
defined
in
26
section
514J.102.
27
j.
“Health
care
professional”
means
the
same
as
defined
in
28
section
514J.102.
29
k.
“Health
care
services”
means
services
for
the
diagnosis,
30
prevention,
treatment,
cure,
or
relief
of
a
health
condition,
31
illness,
injury,
or
disease.
32
l.
“Health
carrier”
means
the
same
as
defined
in
section
33
514J.102.
34
m.
“Nonmedical
switching”
means
a
health
benefit
plan’s
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restrictive
changes
to
the
health
benefit
plan’s
formulary
1
after
the
current
plan
year
has
begun
or
during
the
open
2
enrollment
period
for
the
upcoming
plan
year,
causing
a
covered
3
person
who
is
medically
stable
on
the
covered
person’s
current
4
prescribed
drug
as
determined
by
the
prescribing
health
care
5
professional,
to
switch
to
a
less
costly
alternate
prescription
6
drug.
7
n.
“Open
enrollment”
means
the
yearly
time
period
an
8
individual
can
enroll
in
a
health
benefit
plan.
9
o.
“Utilization
review”
means
the
same
as
defined
in
514F.7.
10
p.
“Utilization
review
organization”
means
the
same
as
11
defined
in
514F.7.
12
2.
Nonmedical
switching.
With
respect
to
a
health
carrier
13
that
has
entered
into
a
health
benefit
plan
with
a
covered
14
person
that
covers
prescription
drug
benefits,
all
of
the
15
following
apply:
16
a.
A
health
carrier,
health
benefit
plan,
or
utilization
17
review
organization
shall
not
limit
or
exclude
coverage
of
18
a
prescription
drug
for
any
covered
person
who
is
medically
19
stable
on
such
drug
as
determined
by
the
prescribing
health
20
care
professional,
if
all
of
the
following
apply:
21
(1)
The
prescription
drug
was
previously
approved
by
the
22
health
carrier
for
coverage
for
the
covered
person.
23
(2)
The
covered
person’s
prescribing
health
care
24
professional
has
prescribed
the
drug
for
the
medical
condition
25
within
the
previous
six
months.
26
(3)
The
covered
person
continues
to
be
an
enrollee
of
the
27
health
benefit
plan.
28
b.
Coverage
of
a
covered
person’s
prescription
drug,
as
29
described
in
paragraph
“a”
,
shall
continue
through
the
last
day
30
of
the
covered
person’s
eligibility
under
the
health
benefit
31
plan,
inclusive
of
any
open
enrollment
period.
32
c.
Prohibited
limitations
and
exclusions
referred
to
in
33
paragraph
“a”
include
but
are
not
limited
to
the
following:
34
(1)
Limiting
or
reducing
the
maximum
coverage
of
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prescription
drug
benefits.
1
(2)
Increasing
cost
sharing
for
a
covered
prescription
2
drug.
3
(3)
Moving
a
prescription
drug
to
a
more
restrictive
tier
if
4
the
health
carrier
uses
a
formulary
with
tiers.
5
(4)
Removing
a
prescription
drug
from
a
formulary,
unless
6
the
United
States
food
and
drug
administration
has
issued
a
7
statement
about
the
drug
that
calls
into
question
the
clinical
8
safety
of
the
drug,
or
the
manufacturer
of
the
drug
has
9
notified
the
United
States
food
and
drug
administration
of
a
10
manufacturing
discontinuance
or
potential
discontinuance
of
the
11
drug
as
required
by
section
506C
of
the
Federal
Food,
Drug,
and
12
Cosmetic
Act,
as
codified
in
21
U.S.C.
§356c.
13
3.
Coverage
exemption
determination
process.
14
a.
To
ensure
continuity
of
care,
a
health
carrier,
health
15
plan,
or
utilization
review
organization
shall
provide
a
16
covered
person
and
prescribing
health
care
professional
with
17
access
to
a
clear
and
convenient
process
to
request
a
coverage
18
exemption
determination.
A
health
carrier,
health
plan,
or
19
utilization
review
organization
may
use
its
existing
medical
20
exceptions
process
to
satisfy
this
requirement.
The
process
21
used
shall
be
easily
accessible
on
the
internet
site
of
the
22
health
carrier,
health
benefit
plan,
or
utilization
review
23
organization.
24
b.
A
health
carrier,
health
benefit
plan,
or
utilization
25
review
organization
shall
respond
to
a
coverage
exemption
26
determination
request
within
seventy-two
hours
of
receipt.
In
27
cases
where
exigent
circumstances
exist,
a
health
carrier,
28
health
benefit
plan,
or
utilization
review
organization
shall
29
respond
within
twenty-four
hours
of
receipt.
If
a
response
by
30
a
health
carrier,
health
benefit
plan,
or
utilization
review
31
organization
is
not
received
within
the
applicable
time
period,
32
the
coverage
exemption
shall
be
deemed
granted.
33
c.
A
coverage
exemption
shall
be
expeditiously
granted
for
a
34
discontinued
health
benefit
plan
if
a
covered
person
enrolls
in
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a
comparable
plan
offered
by
the
same
health
carrier,
and
all
1
of
the
following
conditions
apply:
2
(1)
The
covered
person
is
medically
stable
on
a
prescription
3
drug
as
determined
by
the
prescribing
health
care
professional.
4
(2)
The
prescribing
health
care
professional
continues
5
to
prescribe
the
drug
for
the
covered
person
for
the
medical
6
condition.
7
(3)
In
comparison
to
the
discontinued
health
benefit
plan,
8
the
new
health
benefit
plan
does
any
of
the
following:
9
(a)
Limits
or
reduces
the
maximum
coverage
of
prescription
10
drug
benefits.
11
(b)
Increases
cost
sharing
for
the
prescription
drug.
12
(c)
Moves
the
prescription
drug
to
a
more
restrictive
tier
13
if
the
health
carrier
uses
a
formulary
with
tiers.
14
(d)
Excludes
the
prescription
drug
from
the
formulary.
15
d.
Upon
granting
of
a
coverage
exemption
for
a
drug
16
prescribed
by
a
covered
person’s
prescribing
health
care
17
professional,
a
health
carrier,
health
benefit
plan,
or
18
utilization
review
organization
shall
authorize
coverage
no
19
more
restrictive
than
that
offered
in
a
discontinued
health
20
benefit
plan,
or
than
that
offered
prior
to
implementation
of
21
restrictive
changes
to
the
health
benefit
plan’s
formulary
22
after
the
current
plan
year
began.
23
e.
If
a
determination
is
made
to
deny
a
request
for
a
24
coverage
exemption,
the
health
carrier,
health
benefit
plan,
25
or
utilization
review
organization
shall
provide
the
covered
26
person
or
the
covered
person’s
authorized
representative
and
27
the
authorized
person’s
prescribing
health
care
professional
28
with
the
reason
for
denial
and
information
regarding
the
29
procedure
to
appeal
the
denial.
Any
determination
to
deny
a
30
coverage
exemption
may
be
appealed
by
a
covered
person
or
the
31
covered
person’s
authorized
representative.
32
f.
A
health
carrier,
health
benefit
plan,
or
utilization
33
review
organization
shall
uphold
or
reverse
a
determination
to
34
deny
a
coverage
exemption
within
seventy-two
hours
of
receipt
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of
an
appeal
of
denial.
In
cases
where
exigent
circumstances
1
exist,
a
health
carrier,
health
benefit
plan,
or
utilization
2
review
organization
shall
uphold
or
reverse
a
determination
to
3
deny
a
coverage
exemption
within
twenty-four
hours
of
receipt.
4
If
the
determination
to
deny
a
coverage
exemption
is
not
upheld
5
or
reversed
on
appeal
within
the
applicable
time
period,
the
6
denial
shall
be
deemed
reversed
and
the
coverage
exemption
7
shall
be
deemed
approved.
8
g.
If
a
determination
to
deny
a
coverage
exemption
is
9
upheld
on
appeal,
the
health
carrier,
health
benefit
plan,
10
or
utilization
review
organization
shall
provide
the
covered
11
person
or
covered
person’s
authorized
representative
and
the
12
covered
person’s
prescribing
health
care
professional
with
13
the
reason
for
upholding
the
denial
on
appeal
and
information
14
regarding
the
procedure
to
request
external
review
of
the
15
denial
pursuant
to
chapter
514J.
Any
denial
of
a
request
for
a
16
coverage
exemption
that
is
upheld
on
appeal
shall
be
considered
17
a
final
adverse
determination
for
purposes
of
chapter
514J
and
18
is
eligible
for
a
request
for
external
review
by
a
covered
19
person
or
the
covered
person’s
authorized
representative
20
pursuant
to
chapter
514J.
21
4.
Limitations.
This
section
shall
not
be
construed
to
do
22
any
of
the
following:
23
a.
Prevent
a
health
care
professional
from
prescribing
24
another
drug
covered
by
the
health
carrier
that
the
health
care
25
professional
deems
medically
necessary
for
the
covered
person.
26
b.
Prevent
a
health
carrier
from
doing
any
of
the
following:
27
(1)
Adding
a
prescription
drug
to
its
formulary.
28
(2)
Removing
a
prescription
drug
from
its
formulary
if
the
29
drug
manufacturer
has
removed
the
drug
for
sale
in
the
United
30
States.
31
(3)
Requiring
a
pharmacist
to
effect
a
substitution
of
a
32
generic
or
interchangeable
biological
drug
product
pursuant
to
33
section
155A.32.
34
5.
Enforcement.
The
commissioner
may
take
any
enforcement
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action
under
the
commissioner’s
authority
to
enforce
compliance
1
with
this
section.
2
6.
Applicability.
This
section
is
applicable
to
a
health
3
benefit
plan
that
is
delivered,
issued
for
delivery,
continued,
4
or
renewed
in
this
state
on
or
after
January
1,
2020.
5
EXPLANATION
6
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
7
the
explanation’s
substance
by
the
members
of
the
general
assembly.
8
This
bill
relates
to
the
continuity
of
care
for
covered
9
persons
with
epilepsy,
and
nonmedical
switching
by
health
10
carriers,
health
benefit
plans,
and
utilization
review
11
organizations.
12
The
bill
defines
“nonmedical
switching”
as
a
health
benefit
13
plan’s
restrictive
changes
to
the
health
benefit
plan’s
14
formulary
after
the
current
plan
year
has
begun
or
during
the
15
open
enrollment
period
for
the
upcoming
plan
year,
causing
a
16
covered
person
who
is
medically
stable
on
the
covered
person’s
17
current
prescribed
drug
as
determined
by
the
prescribing
18
health
care
professional,
to
switch
to
a
less
costly
alternate
19
prescription
drug.
20
The
bill
provides
that
during
a
covered
person’s
eligibility
21
under
a
health
benefit
plan,
inclusive
of
any
open
enrollment
22
period,
a
health
plan
carrier,
health
benefit
plan,
or
23
utilization
review
organization
shall
not
limit
or
exclude
24
coverage
of
a
prescription
drug
for
the
covered
person
if
the
25
covered
person
is
medically
stable
on
the
drug
as
determined
26
by
the
prescribing
health
care
professional,
the
drug
was
27
previously
approved
by
the
health
carrier
for
coverage
for
the
28
person,
and
the
person’s
prescribing
health
care
professional
29
has
prescribed
the
drug
for
the
covered
person’s
medical
30
condition
within
the
previous
six
months.
The
bill
includes,
31
as
prohibited
limitations
or
exclusions,
reducing
the
maximum
32
coverage
of
prescription
drug
benefits,
increasing
cost
sharing
33
for
a
covered
drug,
moving
a
drug
to
a
more
restrictive
tier,
34
and
removing
a
drug
from
a
formulary.
A
prescription
drug
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may,
however,
be
removed
from
a
formulary
if
the
United
States
1
food
and
drug
administration
issues
a
statement
regarding
the
2
clinical
safety
of
the
drug,
or
the
manufacturer
of
the
drug
3
notifies
the
United
States
food
and
drug
administration
of
a
4
manufacturing
discontinuance
or
potential
discontinuance
of
the
5
drug
as
required
by
section
506c
of
the
Federal
Food,
Drug,
and
6
Cosmetic
Act.
7
The
bill
requires
a
covered
person
and
prescribing
health
8
care
professional
to
have
access
to
a
process
to
request
a
9
coverage
exemption
determination.
The
bill
defines
“coverage
10
exemption
determination”
as
a
determination
made
by
a
11
health
carrier,
health
benefit
plan,
or
utilization
review
12
organization
whether
to
cover
a
prescription
drug
that
is
13
otherwise
excluded
from
coverage.
14
A
coverage
exemption
determination
request
must
be
approved
15
or
denied
by
the
health
carrier,
health
benefit
plan,
or
16
utilization
review
organization
within
72
hours,
or
within
24
17
hours
if
exigent
circumstances
exist.
If
a
determination
is
18
not
received
within
the
applicable
time
period
the
coverage
19
exemption
is
deemed
granted.
20
The
bill
requires
a
coverage
exemption
to
be
expeditiously
21
granted
for
a
health
benefit
plan
discontinued
for
the
next
22
plan
year
if
a
covered
person
enrolls
in
a
comparable
plan
23
offered
by
the
same
health
carrier,
and
in
comparison
to
the
24
discontinued
health
benefit
plan,
the
new
health
benefit
plan
25
limits
or
reduces
the
maximum
coverage
for
a
prescription
drug,
26
increases
cost
sharing
for
the
prescription
drug,
moves
the
27
prescription
drug
to
a
more
restrictive
tier,
or
excludes
the
28
prescription
drug
from
the
formulary.
29
If
a
coverage
exemption
is
granted,
the
bill
requires
the
30
authorization
of
coverage
that
is
no
more
restrictive
than
that
31
offered
in
a
discontinued
health
benefit
plan,
or
than
that
32
offered
prior
to
implementation
of
restrictive
changes
to
the
33
health
benefit
plan’s
formulary
after
the
current
plan
year
34
began.
35
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S.F.
489
If
a
determination
is
made
to
deny
a
request
for
a
1
coverage
exemption,
the
reason
for
denial
and
the
procedure
2
to
appeal
the
denial
must
be
provided
to
the
requestor.
Any
3
determination
to
deny
a
coverage
exemption
may
be
appealed
to
4
the
health
carrier,
health
benefit
plan,
or
utilization
review
5
organization.
6
A
determination
to
uphold
or
reverse
denial
of
a
coverage
7
exemption
must
be
made
within
72
hours
of
receipt
of
an
appeal,
8
or
within
24
hours
if
exigent
circumstances
exist.
If
a
9
determination
is
not
made
within
the
applicable
time
period,
10
the
denial
is
deemed
reversed
and
the
coverage
exemption
is
11
deemed
approved.
12
If
a
determination
to
deny
a
coverage
exemption
is
upheld
on
13
appeal,
the
reason
for
upholding
the
denial
and
the
procedure
14
to
request
external
review
of
the
denial
pursuant
to
Code
15
chapter
514J
must
be
provided
to
the
individual
who
filed
the
16
appeal.
Any
denial
of
a
request
for
a
coverage
exemption
that
17
is
upheld
on
appeal
is
considered
a
final
adverse
determination
18
for
purposes
of
Code
chapter
514J
and
is
eligible
for
a
request
19
for
external
review
by
a
covered
person
or
the
covered
person’s
20
authorized
representative
pursuant
to
Code
chapter
514J.
21
The
bill
shall
not
be
construed
to
prevent
a
health
care
22
professional
from
prescribing
another
drug
covered
by
the
23
health
carrier
that
the
health
care
professional
deems
24
medically
necessary
for
the
covered
person.
25
The
bill
shall
not
be
construed
to
prevent
a
health
carrier
26
from
adding
a
drug
to
its
formulary
or
removing
a
drug
from
its
27
formulary
if
the
drug
manufacturer
removes
the
drug
for
sale
in
28
the
United
States.
29
The
bill
shall
not
be
construed
to
require
a
pharmacist
30
to
effect
a
substitution
of
a
generic
or
interchangeable
31
biological
drug
product
pursuant
to
Code
section
155A.32.
32
The
bill
allows
the
commissioner
to
take
any
necessary
33
enforcement
action
under
the
commissioner’s
authority
to
34
enforce
compliance
with
the
bill.
35
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489
The
bill
is
applicable
to
health
benefit
plans
that
are
1
delivered,
issued
for
delivery,
continued,
or
renewed
in
this
2
state
on
or
after
January
1,
2020.
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