SB 762 — Creating Preserving Patient Stability Act of 2020

(1) Third-party payers shall not limit or exclude coverage of a biological product, for any covered person who is medically stable on such drug as determined by the prescribing provider, if:

(A) The biological product previously had been approved for coverage by the third-party payer for the covered person;

(b)(c) Coverage of covered person’s medication, as described in subsection (a),(b) of this section, shall continue through the last day of the covered person’s eligibility under the health insurance plan, inclusive of any renewal period.

(c)(d) Prohibited limitations and exclusions referred to in subsection (a)(b) of this section include, but are not limited to:

(3) Moving a prescription drug to a more restrictive tier, if the third-partyagency payer uses a formulary with tiers;

(d)(e) This articlesection does not preclude the prescribing provider from prescribing another biological product covered by the third-partyagency payer that the prescribing provider deems medically necessary for the covered person.

(e)(f) This articlesection does not prohibit athe third-partyagency payer from:

§33-25H-3. (g) ExemptionTo Process.ensure continuity of care, the agency shall provide the covered person and prescribing practitioner with access to a clear, readily accessible, and convenient process to request a coverage exemption determination.

(a)(h) ToA ensurecoverage continuityexemption ofdetermination care,shall expeditiously grant the third-partyexemption payerdetermination shallrequest provideif the agency discontinues the covered personperson’s andprevious prescribinghealth practitionercare withplan accessduring toopen enrollment, the covered person enrolls in a clear,comparable readilyplan accessible,offered andby convenientthe processagency, toand requestthe afollowing Coverageconditions Exemptionare Determination.met:

(b) A Coverage Exemption Determination shall expeditiously grant the exemption determination request if the third-party payer discontinues the covered person’s previous health care plan during open enrollment, the covered person enrolls in a comparable plan offered by the same third-party payer, and the following conditions are met:

(2) The prescribing provider continues to prescribe the biological product to the covered person for the medical condition;

(3) In comparison to the discontinued health insurance plan, the new health insurance plan:

(A) Limits or reduces the maximum coverage of prescription drug benefits;

(B) Increases out-of-pocket costs for the drug;

(C) Moves the drug to a more restrictive tier, if the agency uses a formulary with tiers;

or (D) Excludes the drug from a formulary.

(i) Upon the granting of a coverage exemption determination request, the agency shall authorize coverage no more restrictive than that offered in the discontinued health insurance plan for the biological product prescribed by the covered person’s prescribing provider.

(j) The agency shall respond to a coverage exemption determination request or an appeal within 72 hours of receipt.  In cases where exigent circumstances exist, the agency shall respond within 24 hours of receipt.  Should a response by the agency not be received within this time allotted, the appeal shall be deemed granted.

(k) A covered person has rights of appeal of any adverse decision pursuant to the provisions of this article and the rules promulgated thereunder.

(l) This section is effective for policies, contracts, plans, or agreements, beginning on or after January 1, 2021.

This section applies to all policies, contracts, plans, or agreements subject to this article that are delivered, executed, issued, amended, adjusted, or renewed in this state on or after the effective date of this section.

CHAPTER 33.

INSURANCE.

ARTICLE 15.

Accident and sickness insurance.

§33-15-4u.

(a) As used in this section, the following words and phrases have the same meanings given to them in this section, unless the context clearly indicate otherwise:

(1) “Biological product” means the same as the term is defined in 42 U.S.C.

§ 262.

(2) “Commissioner” means the Insurance Commissioner of West Virginia.

(3) “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirement.

(4) “Coverage exemption determination” means a determination made by the third-party payer to cover a medication that would otherwise be excluded from coverage.

(5) “Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health insurance plan.

(6) “Formulary” means a complete list of drugs eligible for coverage under a health insurance plan.

(7) “Health care provider” means a physician or other health care practitioner licensed, accredited, or certified to perform specified physical, mental, or behavioral health care services consistent with his or her scope of practice under state law.

(8) “Health insurance plan” means a policy, contract, certificate, or agreement entered into, offered, or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse prescription drugs, health care services, and other covered health care benefits.

(9) “Insurer” means an entity licensed by the commissioner to transact accident and sickness insurance in this state and subject to this chapter, but does not include a group health plan or short term limited duration insurance.

(10) “Renewal period” means the term in which a covered person has been continuously enrolled in a health insurance plan after the termination date of a prior year in which the covered person was enrolled.

 (b) For each insurer that has entered into a health insurance plan contract with a covered person that covers prescription drug benefits:

(1) Insurers shall not limit or exclude coverage of a biological product, for any covered person who is medically stable on such drug as determined by the prescribing provider, if:

(A) The biological product previously had been approved for coverage by the insurer for the covered person;

(B)The covered person’s prescribing provider continues to prescribe the biological product for the medical condition;

and (C)  The covered person continues to be an enrollee of the health insurance plan.

(c) Coverage of covered person’s medication, as described in subsection (b) of this section, shall continue through the last day of the covered person’s eligibility under the health insurance plan, inclusive of any renewal period.

(d) Prohibited limitations and exclusions referred to in subsection (b) of this section include, but are not limited to:

(1) Limiting or reducing the maximum coverage of prescription drug benefits;

(2) Increasing out-of-pocket costs for a covered drug;

(3) Moving a prescription drug to a more restrictive tier, if the insurer uses a formulary with tiers;

or (4)  Removing a prescription drug from a formulary.

(e) This section does not preclude the prescribing provider from prescribing another biological product covered by the insurer that the prescribing provider deems medically necessary for the covered person.

(f) This section does not prohibit an insurer from:

(1) Adding a biological product to its formulary;

or (2) Removing a biological product from its formulary if its manufacturer has removed the biological product for sale in the United States.

(g) To ensure continuity of care, the insurer shall provide the covered person and prescribing practitioner with access to a clear, readily accessible, and convenient process to request a coverage exemption determination.

(h) A coverage exemption determination shall expeditiously grant the exemption determination request if the insurer discontinues the covered person’s previous health care plan during open enrollment, the covered person enrolls in a comparable plan offered by the same insurer, and the following conditions are met:

(1) The covered person is medically stable on a biological product as determined by the prescribing provider;

and (3) In comparison to the Discontinueddiscontinued Healthhealth Insuranceinsurance Plan,plan, the new health insurance plan:

(C) Moves the drug to a more restrictive tier, if the third-partyinsurer payer uses a formulary with tiers;

(c)(i) Upon the granting of a Coveragecoverage Exemptionexemption Determinationdetermination request, the third-partyinsurer payer shall authorize coverage no more restrictive than that offered in the Discontinueddiscontinued Healthhealth Insuranceinsurance Planplan for the biological product prescribed by the covered person’s prescribing provider.

(d)(j) The third-partyinsurer payer shall respond to a Coveragecoverage Exemptionexemption Determinationdetermination request or an appeal within 72 hours of receipt.receipt.  In cases where exigent circumstances exist, an insurer shall respond within 24 hours of receipt.  Should a response by the insurer not be received within this time allotted, the appeal shall be deemed granted.

In(k) casesIf wherethe exigentcommissioner circumstancessuspects exist,that aan third-partyinsurer payerhas shallviolated respondany withinprovision 24of hoursthis section, the commissioner may take any enforcement action pursuant to the provisions of receipt.article 34 of this chapter.

Should(l) aThis responsesection byis aeffective third-partyfor payerpolicies, notcontracts, beplans, receivedor withinagreements, thisbeginning timeon allotted,or theafter appealJanuary shall1, be2021. deemed granted.

§33-25H-4. This Enforcement.section applies to all policies, contracts, plans, or agreements, subject to this article that are delivered, executed, issued, amended, adjusted, or renewed in this state on or after the effective date of this section.

IfARTICLE the16.  commissionerGROUP suspectsACCIDENT thatAND aSICKNESS third-partyINSURANCE. payer has violated any provision of this article, the commissioner may take any enforcement action pursuant to the provisions of §33-2-1 et seq.

of§33-16-3ff. this code.

 (a)  As Note:used in this section, the following words and phrases have the same meanings given to them in this section, unless the context clearly indicate otherwise:

The(1) purpose“Biological ofproduct” thismeans billthe issame to ensure that covered persons who are stable on their biological product prescription drug regimens, as determined by the prescribingterm provider,is havedefined continuous care and that third-party payers cannot make restrictive changes to their formularies after a plan year has begun or has been renewed, resulting in increased42 cost-sharingU.S.C. or loss of access to a medication—a practice referred to as “nonmedical switching.”   Strike-through indicates language that would be stricken from a heading or present law, and underscoring indicates new language that would be added.

Bill§ Status  | 262. Bill Tracking  |  Legacy WV Code  |  Bulletin Board  |  District Maps  |  Senate Roster  |  House Roster  |  Live  |  Blog  |  Jobs  |  Links  |  Home This Web site is maintained by the West Virginia Legislature's Office of Reference & Information.

(2) “Commissioner” means the Insurance Commissioner of West Virginia.

(3) “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible or other out-of-pocket expense requirement.

(4) “Coverage exemption determination” means a determination made by the third-party payer to cover a medication that would otherwise be excluded from coverage.

(5) “Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health insurance plan.

(6) “Formulary” means a complete list of drugs eligible for coverage under a health insurance plan.

(7) “Health care provider” means a physician or other health care practitioner licensed, accredited, or certified to perform specified physical, mental, or behavioral health care services consistent with his or her scope of practice under state law.

(8) “Health insurance plan” means a policy, contract, certificate, or agreement entered into, offered, or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse prescription drugs, health care services, and other covered health care benefits.

(9) “Insurer” means an entity licensed by the commissioner to transact accident and sickness insurance in this state and subject to this chapter, but does not include a group health plan or short term limited duration insurance.

(10) “Renewal period” means the term in which a covered person has been continuously enrolled in a health insurance plan after the termination date of a prior year in which the covered person was enrolled.

(b) For each insurer that has entered into a health insurance plan contract with a covered person that covers prescription drug benefits:

(1) Insurers shall not limit or exclude coverage of a biological product, for any covered person who is medically stable on such drug as determined by the prescribing provider, if:

(A) The biological product previously had been approved for coverage by the insurer for the covered person;

(B)The covered person’s prescribing provider continues to prescribe the biological product for the medical condition;

and (C)  The covered person continues to be an enrollee of the health insurance plan.

(c) Coverage of covered person’s medication, as described in subsection (b) of this section, shall continue through the last day of the covered person’s eligibility under the health insurance plan, inclusive of any renewal period.

(d) Prohibited limitations and exclusions referred to in subsection (b) of this section include, but are not limited to:

(1) Limiting or reducing the maximum coverage of prescription drug benefits;

(2) Increasing out-of-pocket costs for a covered drug;

(3) Moving a prescription drug to a more restrictive tier, if the insurer uses a formulary with tiers;

or (4)  Removing a prescription drug from a formulary.

(e) This section does not preclude the prescribing provider from prescribing another biological product covered by the insurer that the prescribing provider deems medically necessary for the covered person.

(f) This section does not prohibit an insurer from:

(1) Adding a biological product to its formulary;

or (2) Removing a biological product from its formulary if its manufacturer has removed the biological product for sale in the United States.

(g) To ensure continuity of care, the insurer shall provide the covered person and prescribing practitioner with access to a clear, readily accessible, and convenient process to request a coverage exemption determination.

(h) A coverage exemption determination shall expeditiously grant the exemption determination request if the insurer discontinues the covered person’s previous health care plan during open enrollment, the covered person enrolls in a comparable plan offered by the same insurer, and the following conditions are met:

(1) The covered person is medically stable on a biological product as determined by the prescribing provider;

and (2) The prescribing provider continues to prescribe the biological product to the covered person for the medical condition;

and (3) In comparison to the discontinued health insurance plan, the new health insurance plan:

(A) Limits or reduces the maximum coverage of prescription drug benefits;

(B) Increases out-of-pocket costs for the drug;

(C) Moves the drug to a more restrictive tier, if the insurer uses a formulary with tiers;

or (D) Excludes the drug from a formulary.

(i) Upon the granting of a coverage exemption determination request, the insurer shall authorize coverage no more restrictive than that offered in the discontinued health insurance plan for the biological product prescribed by the covered person’s prescribing provider.

(j) The insurer shall respond to a coverage exemption determination request or an appeal within 72 hours of receipt.  In cases where exigent circumstances exist, an insurer shall respond within 24 hours of receipt.  Should a response by the insurer not be received within this time allotted, the appeal shall be deemed granted.

(k) If the commissioner suspects that an insurer has violated any provision of this section, the commissioner may take any enforcement action pursuant to the provisions of article 34 of this chapter.

(l) This section is effective for policies, contracts, plans, or agreements, beginning on or after January 1, 2021.

This section applies to all policies, contracts, plans, or agreements, subject to this article that are delivered, executed, issued, amended, adjusted, or renewed in this state on or after the effective date of this section.

ARTICLE 24.

HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH SERVICE CORPORATIONS.

§33-24-7u.

(a) As used in this section, the following words and phrases have the same meanings given to them in this section, unless the context clearly indicate otherwise:

(1) “Biological product” means the same as the term is defined in 42 U.S.C.

§ 262.

(2) “Commissioner” means the Insurance Commissioner of West Virginia.

(3) “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible or other out-of-pocket expense requirement.

(4) “Coverage exemption determination” means a determination made by the third-party payer to cover a medication that would otherwise be excluded from coverage.

(5) “Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health insurance plan.

(6) “Formulary” means a complete list of drugs eligible for coverage under a health insurance plan.

(7) “Health care provider” means a physician or other health care practitioner licensed, accredited, or certified to perform specified physical, mental, or behavioral health care services consistent with his or her scope of practice under state law.

(8) “Health insurance plan” means a policy, contract, certificate, or agreement entered into, offered, or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse prescription drugs, health care services, and other covered health care benefits.

(9) “Insurer” means an entity licensed by the commissioner to transact accident and sickness insurance in this state and subject to this chapter, but does not include a group health plan or short term limited duration insurance.

(10) “Renewal period” means the term in which a covered person has been continuously enrolled in a health insurance plan after the termination date of a prior year in which the covered person was enrolled.

 (b) For each insurer that has entered into a health insurance plan contract with a covered person that covers prescription drug benefits:

(1) Insurers shall not limit or exclude coverage of a biological product, for any covered person who is medically stable on such drug as determined by the prescribing provider, if:

(A) The biological product previously had been approved for coverage by the insurer for the covered person;

(B)The covered person’s prescribing provider continues to prescribe the biological product for the medical condition;

and (C)  The covered person continues to be an enrollee of the health insurance plan.

(c) Coverage of covered person’s medication, as described in subsection (b) of this section, shall continue through the last day of the covered person’s eligibility under the health insurance plan, inclusive of any renewal period.

(d) Prohibited limitations and exclusions referred to in subsection (b) of this section include, but are not limited to:

(1) Limiting or reducing the maximum coverage of prescription drug benefits;

(2) Increasing out-of-pocket costs for a covered drug;

(3) Moving a prescription drug to a more restrictive tier, if the insurer uses a formulary with tiers;

or (4)  Removing a prescription drug from a formulary.

(e) This section does not preclude the prescribing provider from prescribing another biological product covered by the insurer that the prescribing provider deems medically necessary for the covered person.

(f) This section does not prohibit an insurer from:

(1) Adding a biological product to its formulary;

or (2) Removing a biological product from its formulary if its manufacturer has removed the biological product for sale in the United States.

(g) To ensure continuity of care, the insurer shall provide the covered person and prescribing practitioner with access to a clear, readily accessible, and convenient process to request a coverage exemption determination.

(h) A coverage exemption determination shall expeditiously grant the exemption determination request if the insurer discontinues the covered person’s previous health care plan during open enrollment, the covered person enrolls in a comparable plan offered by the same insurer, and the following conditions are met:

(1) The covered person is medically stable on a biological product as determined by the prescribing provider;

and (2) The prescribing provider continues to prescribe the biological product to the covered person for the medical condition;

and (3) In comparison to the discontinued health insurance plan, the new health insurance plan:

(A) Limits or reduces the maximum coverage of prescription drug benefits;

(B) Increases out-of-pocket costs for the drug;

(C) Moves the drug to a more restrictive tier, if the insurer uses a formulary with tiers;

or (D) Excludes the drug from a formulary.

(i) Upon the granting of a coverage exemption determination request, the insurer shall authorize coverage no more restrictive than that offered in the discontinued health insurance plan for the biological product prescribed by the covered person’s prescribing provider.

(j) The insurer shall respond to a coverage exemption determination request or an appeal within 72 hours of receipt.  In cases where exigent circumstances exist, an insurer shall respond within 24 hours of receipt.  Should a response by the insurer not be received within this time allotted, the appeal shall be deemed granted.

(k) If the commissioner suspects that an insurer has violated any provision of this section, the commissioner may take any enforcement action pursuant to the provisions of article 34 of this chapter.

(l) This section is effective for policies, contracts, plans, or agreements, beginning on or after January 1, 2021.

This section applies to all policies, contracts, plans, or agreements, subject to this article that are delivered, executed, issued, amended, adjusted, or renewed in this state on or after the effective date of this section.

ARTICLE 25.  HEALTH CARE CORPORATIONS.

§33-25-8r.

(a) As used in this section, the following words and phrases have the same meanings given to them in this section, unless the context clearly indicate otherwise:

(1) “Biological product” means the same as the term is defined in 42 U.S.C.

§ 262.

(2) “Commissioner” means the Insurance Commissioner of West Virginia.

(3) “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible or other out-of-pocket expense requirement.

(4) “Coverage exemption determination” means a determination made by the third-party payer to cover a medication that would otherwise be excluded from coverage.

(5) “Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health insurance plan.

(6) “Formulary” means a complete list of drugs eligible for coverage under a health insurance plan.

(7) “Health care provider” means a physician or other health care practitioner licensed, accredited, or certified to perform specified physical, mental, or behavioral health care services consistent with his or her scope of practice under state law.

(8) “Health insurance plan” means a policy, contract, certificate, or agreement entered into, offered, or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse prescription drugs, health care services, and other covered health care benefits.

(9) “Insurer” means an entity licensed by the commissioner to transact accident and sickness insurance in this state and subject to this chapter, but does not include a group health plan or short term limited duration insurance.

(10) “Renewal period” means the term in which a covered person has been continuously enrolled in a health insurance plan after the termination date of a prior year in which the covered person was enrolled.

 (b) For each insurer that has entered into a health insurance plan contract with a covered person that covers prescription drug benefits:

(1) Insurers shall not limit or exclude coverage of a biological product, for any covered person who is medically stable on such drug as determined by the prescribing provider, if:

(A) The biological product previously had been approved for coverage by the insurer for the covered person;

(B)The covered person’s prescribing provider continues to prescribe the biological product for the medical condition;

and (C)  The covered person continues to be an enrollee of the health insurance plan.

(c) Coverage of covered person’s medication, as described in subsection (b) of this section, shall continue through the last day of the covered person’s eligibility under the health insurance plan, inclusive of any renewal period.

(d) Prohibited limitations and exclusions referred to in subsection (b) of this section include, but are not limited to:

(1) Limiting or reducing the maximum coverage of prescription drug benefits;

(2) Increasing out-of-pocket costs for a covered drug;

(3) Moving a prescription drug to a more restrictive tier, if the insurer uses a formulary with tiers;

or (4)  Removing a prescription drug from a formulary.

(e) This section does not preclude the prescribing provider from prescribing another biological product covered by the insurer that the prescribing provider deems medically necessary for the covered person.

(f) This section does not prohibit an insurer from:

(1) Adding a biological product to its formulary;

or (2) Removing a biological product from its formulary if its manufacturer has removed the biological product for sale in the United States.

(g) To ensure continuity of care, the insurer shall provide the covered person and prescribing practitioner with access to a clear, readily accessible, and convenient process to request a coverage exemption determination.

(h) A coverage exemption determination shall expeditiously grant the exemption determination request if the insurer discontinues the covered person’s previous health care plan during open enrollment, the covered person enrolls in a comparable plan offered by the same insurer, and the following conditions are met:

(1) The covered person is medically stable on a biological product as determined by the prescribing provider;

and (2) The prescribing provider continues to prescribe the biological product to the covered person for the medical condition;

and (3) In comparison to the discontinued health insurance plan, the new health insurance plan:

(A) Limits or reduces the maximum coverage of prescription drug benefits;

(B) Increases out-of-pocket costs for the drug;

(C) Moves the drug to a more restrictive tier, if the insurer uses a formulary with tiers;

or (D) Excludes the drug from a formulary.

(i) Upon the granting of a coverage exemption determination request, the insurer shall authorize coverage no more restrictive than that offered in the discontinued health insurance plan for the biological product prescribed by the covered person’s prescribing provider.

(j) The insurer shall respond to a coverage exemption determination request or an appeal within 72 hours of receipt.  In cases where exigent circumstances exist, an insurer shall respond within 24 hours of receipt.  Should a response by the insurer not be received within this time allotted, the appeal shall be deemed granted.

(k) If the commissioner suspects that an insurer has violated any provision of this section, the commissioner may take any enforcement action pursuant to the provisions of article 34 of this chapter.

(l) This section is effective for policies, contracts, plans, or agreements, beginning on or after January 1, 2021.

This section applies to all policies, contracts, plans, or agreements, subject to this article that are delivered, executed, issued, amended, adjusted, or renewed in this state on or after the effective date of this section.

ARTICLE 25A.

HEALTH MAINTENANCE ORGANIZATION ACT.

§33-25A-8u.

(a) As used in this section, the following words and phrases have the same meanings given to them in this section, unless the context clearly indicate otherwise:

(1) “Biological product” means the same as the term is defined in 42 U.S.C.

§ 262.

(2) “Commissioner” means the Insurance Commissioner of West Virginia.

(3) “Cost-sharing” means any coverage limit, copayment, coinsurance, deductible or other out-of-pocket expense requirement.

(4) “Coverage exemption determination” means a determination made by the third-party payer to cover a medication that would otherwise be excluded from coverage.

(5) “Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health insurance plan.

(6) “Formulary” means a complete list of drugs eligible for coverage under a health insurance plan.

(7) “Health care provider” means a physician or other health care practitioner licensed, accredited, or certified to perform specified physical, mental, or behavioral health care services consistent with his or her scope of practice under state law.

(8) “Health insurance plan” means a policy, contract, certificate, or agreement entered into, offered, or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse prescription drugs, health care services, and other covered health care benefits.

(9) “Insurer” means an entity licensed by the commissioner to transact accident and sickness insurance in this state and subject to this chapter, but does not include a group health plan or short term limited duration insurance.

(10) “Renewal period” means the term in which a covered person has been continuously enrolled in a health insurance plan after the termination date of a prior year in which the covered person was enrolled.

(b) For each insurer that has entered into a health insurance plan contract with a covered person that covers prescription drug benefits:

(1) Insurers shall not limit or exclude coverage of a biological product, for any covered person who is medically stable on such drug as determined by the prescribing provider, if:

(A) The biological product previously had been approved for coverage by the insurer for the covered person;

(B)The covered person’s prescribing provider continues to prescribe the biological product for the medical condition;

and (C)  The covered person continues to be an enrollee of the health insurance plan.

(c) Coverage of covered person’s medication, as described in subsection (b) of this section, shall continue through the last day of the covered person’s eligibility under the health insurance plan, inclusive of any renewal period.

(d) Prohibited limitations and exclusions referred to in subsection (b) of this section include, but are not limited to:

(1) Limiting or reducing the maximum coverage of prescription drug benefits;

(2) Increasing out-of-pocket costs for a covered drug;

(3) Moving a prescription drug to a more restrictive tier, if the insurer uses a formulary with tiers;

or (4)  Removing a prescription drug from a formulary.

(e) This section does not preclude the prescribing provider from prescribing another biological product covered by the insurer that the prescribing provider deems medically necessary for the covered person.

(f) This section does not prohibit an insurer from:

(1) Adding a biological product to its formulary;

or (2) Removing a biological product from its formulary if its manufacturer has removed the biological product for sale in the United States.

(g) To ensure continuity of care, the insurer shall provide the covered person and prescribing practitioner with access to a clear, readily accessible, and convenient process to request a coverage exemption determination.

(h) A coverage exemption determination shall expeditiously grant the exemption determination request if the insurer discontinues the covered person’s previous health care plan during open enrollment, the covered person enrolls in a comparable plan offered by the same insurer, and the following conditions are met:

(1) The covered person is medically stable on a biological product as determined by the prescribing provider;

and (2) The prescribing provider continues to prescribe the biological product to the covered person for the medical condition;

and (3) In comparison to the discontinued health insurance plan, the new health insurance plan:

(A) Limits or reduces the maximum coverage of prescription drug benefits;

(B) Increases out-of-pocket costs for the drug;

(C) Moves the drug to a more restrictive tier, if the insurer uses a formulary with tiers;

or (D) Excludes the drug from a formulary.

(i) Upon the granting of a coverage exemption determination request, the insurer shall authorize coverage no more restrictive than that offered in the discontinued health insurance plan for the biological product prescribed by the covered person’s prescribing provider.

(j) The insurer shall respond to a coverage exemption determination request or an appeal within 72 hours of receipt.  In cases where exigent circumstances exist, an insurer shall respond within 24 hours of receipt.  Should a response by the insurer not be received within this time allotted, the appeal shall be deemed granted.

(k) If the commissioner suspects that an insurer has violated any provision of this section, the commissioner may take any enforcement action pursuant to the provisions of article 34 of this chapter.

(l) This section is effective for policies, contracts, plans, or agreements, beginning on or after January 1, 2021.

This section applies to all policies, contracts, plans, or agreements, subject to this article that are delivered, executed, issued, amended, adjusted, or renewed in this state on or after the effective date of this section.

NOTE:  The purpose of this bill is to ensure that covered persons who are stable on their biological product prescription drug regimens, as determined by the prescribing provider, have continuous care and that third-party payers cannot make restrictive changes to their formularies after a plan year has begun or has been renewed, resulting in increased cost-sharing or loss of access to a medication--a practice referred to as “nonmedical switching.”   Strike-through indicates language that would be stricken from a heading or present law and underscoring indicates new language that would be added.

  Bill Status  |  Bill Tracking  |  Legacy WV Code  |  Bulletin Board  |  District Maps  |  Senate Roster  |  House Roster  |  Live  |  Blog  |  Jobs  |  Links  |  Home This Web site is maintained by the West Virginia Legislature's Office of Reference & Information.