§ 38a-477jj — Prescription drug formularies and lists of covered drugs. Removal or movement to higher cost-sharing tier during plan year prohibited. Exceptions. Study and report.

(a) For the purposes of this section: (1) “Affordable Care Act” has the same meaning as provided in section 38a-1080 ; (2) “Exchange” has the same meaning as provided in section 38a-1080 ; (3) “Health benefit plan” has the same meaning as provided in section 38a-1080 , except that such term shall not include a grandfathered health plan as such term is used in the Affordable Care Act; (4) “Health carrier” has the same meaning as provided in section 38a-1080 ; (5) “Office of Health Strategy” means the Office of Health Strategy established under section 19a-754a ; and (6) “Qualified health plan” has the same meaning as provided in section 38a-1080 . (b) Notwithstanding any provision of the general statutes and except as provided in subsection (c) of this section, no health carrier offering a health benefit plan in this state on or after January 1, 2022, that includes a pharmacy benefit and uses a drug formulary or list of covered drugs may: (1) Remove a prescription drug from the drug formulary or list of covered drugs during a plan year; or (2) Move a prescription drug from a cost-sharing tier that imposes a lesser coinsurance, copayment or deductible for the prescription drug to a cost-sharing tier that imposes a greater coinsurance, copayment or deductible for the prescription drug during a plan year, unless the prescription drug is subject to an in-network coinsurance, copayment or deductible that is not greater than forty dollars per prescription per month in any tier. (c) A health carrier offering a health benefit plan in this state on or after January 1, 2022, that includes a pharmacy benefit and uses a drug formulary or list of covered drugs may: (1) Remove a prescription drug from the drug formulary or list of covered drugs, upon at least ninety days' advance notice to a covered person and the covered person's treating physician, if: (A) The federal Food and Drug Administration issues an announcement, guidance, notice, warning or statement concerning the prescription drug that calls into question the clinical safety of the prescription drug, unless the covered person's treating physician states, in writing, that the prescription drug remains medically necessary despite such announcement, guidance, notice, warning or statement; or (B) The prescription drug is approved by the federal Food and Drug Administration for use without a prescription; and (2) Move a brand-name prescription drug from a cost-sharing tier that imposes a lesser coinsurance, copayment or deductible for the brand-name prescription drug to a cost-sharing tier that imposes a greater coinsurance, copayment or deductible for the brand-name prescription drug if the health carrier adds to the drug formulary or list of covered drugs a generic prescription drug that is: (A) Approved by the federal Food and Drug Administration for use as an alternative to such brand-name prescription drug; and (B) In a cost-sharing tier that imposes a coinsurance, copayment or deductible for the generic prescription drug that is lesser than the coinsurance, copayment or deductible that is imposed for such brand-name prescription drug. (d) Nothing in this section shall prevent or prohibit a health carrier from adding a prescription drug to a formulary or list of covered drugs at any time. (e) (1) The Office of Health Strategy shall, at least annually, conduct a study to determine the impact that the requirements established in subsections (a) to (d), inclusive, of this section have on the cost of health benefit plans offered, delivered, issued for delivery, renewed, amended or continued in this state and qualified health plans offered and sold through the exchange. (2) Not later than January 31, 2023, and annually thereafter, the Office of Health Strategy shall submit a report, in accordance with the provisions of section 11-4a , to the commissioner and the joint standing committee of the General Assembly having cognizance of matters relating to insurance. Such report shall disclose the results of the study conducted pursuant to subdivision (1) of this subsection for the preceding year.

Legislative History

(P.A. 21-96, S. 2.) History: P.A. 21-96 effective January 1, 2022.