§ 31A-22-661 — Health benefit plan procedures related to prescription drugs.

(1) As used in this section, "long-term drug" means an enrollee's prescription drug where the prescription has been active for at least 180 days with the health benefit plan.
(2) (2)(a) Except as provided in Subsection (2)(b), before a health benefit plan requires an enrollee to change from a prescribed long-term drug to another drug, the health benefit plan shall:
(2)(a)(i) at least 30 days before the day on which the health benefit plan will require the enrollee to change from the long-term drug to another drug, provide notice that the health benefit plan will require the individual to change to another drug; and
(2)(a)(ii) provide a justification for the change upon request.
(2)(b) Subsection (2)(a) does not apply if:
(2)(b)(i) the change requires the individual to try a generic or a biosimilar of the long-term drug; or
(2)(b)(ii) the long-term drug is not on the health benefit plan's formulary.
(3) A health benefit plan shall provide an enrollee a justification as to why an enrollee must try a certain drug before a health benefit plan will cover a different prescribed drug.
(4) This section does not apply to a drug that is provided under the health benefit plan's medical benefit.

Legislative History

Enacted by Chapter 262, 2024 General Session