6147-S AMH HCW H4994.1
 
SSB 6147 - H COMM AMD 
By Committee on Health Care & Wellness
ADOPTED 02/27/2018
Strike everything after the enacting clause and insert the following:
NEW SECTION.  Sec. 1.  "A new section is added to chapter 48.43 RCW to read as follows:
(1) For health plans that include a prescription drug benefit, an issuer must, at least once every plan year, provide enrollees with a separate written notification of the substitution process that the enrollee or his or her provider may use to seek coverage of a prescription drug that is not on the formulary. The notice must include the following in plain language:
(a) A clear explanation of the substitution process, including, but not limited to, timelines for standard or expedited review, documentation requirements, the availability of internal appeals, and the availability of review by an independent review organization if applicable; and
(b) A statement that the issuer must continue to cover a drug that is removed from the issuer's formulary for the time period required for an enrollee who is taking the medication at the time of the formulary change to use an issuer's substitution process to request continuation of coverage for the removed medication and receive a decision through that process, unless patient safety requires swifter replacement.
(2) An issuer providing prior notice to an enrollee that a drug will be removed from the issuer's formulary must include in the notice the information required in subsection (1) of this section.
(3) The commissioner shall, by December 31, 2018, develop a model form that issuers may use to make the notifications required in this section.
(4) Unless prohibited by state or federal law pertaining to controlled substances, an issuer that grants a substitution request for a prescription drug that is not on the issuer's formulary must provide coverage for the drug with no prior authorization for the remainder of the plan year.
(5) This section applies to health plans issued or renewed on or after January 1, 2019."
Correct the title.
EFFECT: Requires health plans to provide to enrollees, at least once a year, written notification of the health plan's substitution process that the enrollee may use to seek coverage of a prescription drug that is not on the formulary. Requires the notice to include a clear explanation of the process and a statement that the issuer must continue to cover a drug that is removed from the formulary during the substitution process, unless patient safety requires swifter replacement. Requires the same notice to be provided to enrollees when an issuer is providing prior notice that a drug will be removed from the formulary. Requires the Insurance Commissioner to develop a model form for the notifications. Requires a carrier to continue to cover, without prior authorization, a nonformulary prescription drug that was approved under its substitution process for the remainder of the plan year, unless otherwise required by state or federal laws pertaining to controlled substances. Removes the requirement that health plans continue to cover prescription drugs under certain circumstances. Removes the prohibition against issuers increasing copayment or coinsurance amounts during the plan year. Removes the intent section.
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