The bill SB1164 seeks to improve prescription drug coverage by implementing specific protections for individuals already on prescribed medications. It prohibits pharmacy benefit managers (PBMs) from limiting or excluding coverage for these drugs, provided the individuals remain enrolled with their insurer. The bill requires PBMs to notify individuals and healthcare providers of any formulary changes at least 60 days in advance and establishes a process for requesting coverage exemptions for nonformulary drugs. Additionally, any denial of coverage must be documented in writing, including the reasons for denial, and individuals are granted the right to appeal such decisions.

The new legislation introduces clear regulations that were not previously outlined in current law, ensuring continuity of care and enhancing transparency in the coverage determination process. It mandates that coverage for previously approved drugs continues through the end of the individual's plan year and restricts formulary changes without proper notification and authorization from healthcare providers. The bill also includes provisions for civil penalties against PBMs or insurers that fail to comply with these requirements, aiming to enhance patient access to necessary medications and provide a structured approach to formulary changes.

Statutes affected:
Introduced Version: 20-3335
Senate Engrossed Version: 20-3335