Purpose of the Bill

The purpose of this bill is to regulate health plan formulary changes, ensuring that patients have consistency in their prescription drug coverage through the duration of their plan year. It aims to prevent unforeseen increases in costs or loss of coverage for medications unless certain conditions are met.

Main Provisions

• Formulary Stability: Health plans are prohibited from removing a previously prescribed drug from their formulary or shifting it to a benefit category that would increase the enrollee's costs during the plan year.

• Exceptions to the Rule:

  • A drug can be removed if it is deemed unsafe or is withdrawn by the FDA or its manufacturer.
  • Formulary removal is permitted if research or clinical guidelines recommend it due to previously unknown risks that pose imminent harm to patients.
  • Brand-name drugs can be removed or re-categorized to increase costs if a lower-cost, FDA-rated equivalent generic or interchangeable biologic is added. This action requires a 60-day advance notification to involved parties.

Significant Changes to Existing Law

This bill introduces a new legal framework that restricts health plans from making mid-year formulary changes affecting costs for enrollees, enhancing prescription stability for those relying on specific medications.

Relevant Terms

formulary, health plan, FDA, drug safety, prescription drug, generic drug, biologic drug, drug withdrawal, benefit category, cost increase, Orange Book, Purple Book, patient harm.