House File 626 - Reprinted HOUSE FILE 626 BY COMMITTEE ON COMMERCE (SUCCESSOR TO HF 96) (As Amended and Passed by the House March 9, 2023 ) A BILL FOR An Act relating to continuity of care and nonmedical switching 1 by health carriers, health benefit plans, and utilization 2 review organizations, and including applicability 3 provisions. 4 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 5 HF 626 (3) 90 ko/rn/md

H.F. 626 Section 1. NEW SECTION . 514F.9 Continuity of care —— 1 nonmedical switching. 2 1. Definitions. For the purpose of this section: 3 a. “Commissioner” means the commissioner of insurance. 4 b. “Cost sharing” means any coverage limit, copayment, 5 coinsurance, deductible, or other out-of-pocket expense 6 requirement. 7 c. “Covered person” means the same as defined in section 8 514J.102. 9 d. “Demonstrated bioavailability” means the same as defined 10 in section 155A.3. 11 e. “Formulary” means a complete list of prescription drugs 12 eligible for coverage under a health benefit plan. 13 f. “Generic name” means the same as defined in section 14 155A.3. 15 g. “Health benefit plan” means the same as defined in 16 section 514J.102. 17 h. “Health care professional” means the same as defined in 18 section 514J.102. 19 i. “Health care services” means the same as defined in 20 section 514J.102. 21 j. “Health carrier” means an entity subject to the 22 insurance laws and regulations of this state, or subject 23 to the jurisdiction of the commissioner, including an 24 insurance company offering sickness and accident plans, a 25 health maintenance organization, a nonprofit health service 26 corporation, a plan established pursuant to chapter 509A 27 for public employees, or any other entity providing a plan 28 of health insurance, health care benefits, or health care 29 services. “Health carrier” does not include the department 30 of human services, or a managed care organization acting 31 pursuant to a contract with the department of human services to 32 administer the medical assistance program under chapter 249A 33 or the healthy and well kids in Iowa (hawk-i) program under 34 chapter 514I. 35 -1- HF 626 (3) 90 ko/rn/md 1/ 3

H.F. 626 k. “Interchangeable biological product” means the same as 1 defined in section 155A.3. 2 l. “Utilization review organization” means the same as 3 defined in section 514F.7. 4 2. Nonmedical switching. With respect to a health carrier 5 that has entered into a health benefit plan with a covered 6 person that covers prescription drug benefits, all of the 7 following apply: 8 a. A health carrier, health benefit plan, or utilization 9 review organization shall not limit or exclude coverage of 10 a prescription drug for any covered person who is medically 11 stable on such drug as determined by the prescribing health 12 care professional, if all of the following apply: 13 (1) The prescription drug was previously approved by the 14 health carrier for coverage for the covered person. 15 (2) The covered person’s prescribing health care 16 professional has prescribed the drug for the covered person’s 17 medical condition within the previous six months. 18 (3) The covered person continues to be an enrollee of the 19 health benefit plan. 20 b. Coverage of a covered person’s prescription drug, as 21 described in paragraph “a” , shall continue through the last day 22 of the covered person’s eligibility under the health benefit 23 plan, or through the last day of the health benefit plan year, 24 whichever is earlier. 25 c. Prohibited limitations and exclusions referred to in 26 paragraph “a” include but are not limited to the following: 27 (1) Limiting or reducing the maximum coverage of 28 prescription drug benefits. 29 (2) Increasing cost sharing for a covered prescription 30 drug. 31 (3) Moving a prescription drug to a more restrictive tier if 32 the health carrier uses a formulary with tiers. 33 (4) Removing a prescription drug from a formulary, unless 34 the United States food and drug administration has issued a 35 -2- HF 626 (3) 90 ko/rn/md 2/ 3

H.F. 626 statement about the drug that calls into question the clinical 1 safety of the drug, or the manufacturer of the drug has 2 notified the United States food and drug administration of a 3 manufacturing discontinuance or potential discontinuance of the 4 drug as required by section 506C of the Federal Food, Drug, and 5 Cosmetic Act, as codified in 21 U.S.C. §356c. 6 d. This subsection shall not be construed to prohibit 7 a substitution, a formulary change, or a preference by a 8 health carrier for a prescribed drug product that has the same 9 generic name and demonstrated bioavailability, or that is an 10 interchangeable biological product. 11 3. Limitations. This section shall not be construed to do 12 any of the following: 13 a. Prevent a health care professional from prescribing 14 another drug covered by the health carrier that the health care 15 professional deems medically necessary for the covered person. 16 b. Prevent a health carrier from doing any of the following: 17 (1) Adding a prescription drug to its formulary. 18 (2) Removing a prescription drug from its formulary if the 19 drug manufacturer has removed the drug for sale in the United 20 States. 21 4. Enforcement. The commissioner may take any enforcement 22 action under the commissioner’s authority to enforce compliance 23 with this section. 24 Sec. 2. APPLICABILITY. This Act applies to a health benefit 25 plan that is delivered, issued for delivery, continued, or 26 renewed in this state on or after January 1, 2024. 27 -3- HF 626 (3) 90 ko/rn/md 3/ 3