How H1313 changes current law

AI-generated reading aid from the bill's amendatory text — verify against the official bill.

This bill adds new regulations on health benefit carriers regarding the coverage and administration of clinician-administered drugs.

• Chapter 176O

  Section 30. (a) In this section: (1) "Clinician-administered drug" means an outpatient prescription drug other than a vaccine that: (A) cannot reasonably be self-administered by the patient to whom the drug is prescribed or by an individual assisting the patient with the self-administration; and (B) is typically administered: (i) by a health care provider authorized under the laws of this state to administer the drug, including when acting under a physician’s delegation and supervision; and (ii) in a physician’s office, hospital outpatient infusion center, or other clinical setting. (b) A health benefit carrier: (1) shall not refuse to authorize, approve, or pay a participating provider for providing covered clinician-administered drugs and related services to covered persons; (2) shall not impose coverage or benefits limitations, or require an enrollee to pay an additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or other penalty when obtaining clinician-administered drugs from a health care provider authorized under the laws of this state to administer clinician-administered drugs, or a pharmacy; (3) shall not interfere with the patient's right to choose to obtain a clinician-administered drug from their provider or pharmacy of choice, including inducement, steering, or offering financial or other incentives; (4) shall not require clinician-administered drugs to be dispensed by a pharmacy selected by the health plan; (5) shall not limit or exclude coverage for a clinician-administered drug when not dispensed by a pharmacy selected by the health plan, if such drug would otherwise be covered; (6) shall not reimburse at a lesser amount clinician-administered drugs dispensed by a pharmacy not selected by the health plan; (7) shall not condition, deny, restrict, refuse to authorize or approve, or reduce payment to a participating provider for providing covered clinician-administered drugs and related services to covered persons when all criteria for medical necessity are met, because the participating provider obtains clinician-administered drugs from a pharmacy that is not a participating provider in the health benefit issuer’s network; (8) shall not require that an enrollee pay an additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or any other form of price increase for clinician-administered drugs when not dispensed by a pharmacy selected by the health plan; (9) shall not require a specialty pharmacy to dispense a clinician-administered medication directly to a patient with the intention that the patient will transport the medication to a healthcare provider for administration (c) A health benefit carrier may offer, but shall not require: (1) the use of a home infusion pharmacy to dispense clinician-administered drugs to patients in their homes or; (2) the use of an infusion site external to a patient’s provider office or clinic.

  This establishes specific protections and requirements for health benefit carriers related to the authorization and coverage of clinician-administered drugs.