The proposed bill would update current statutes by introducing new regulations for pharmacy benefit managers (PBMs) regarding prescription drug coverage. Specifically, it would prohibit PBMs from limiting or excluding coverage for a prescription drug if the drug was previously approved for a covered individual and the individual remains insured. Additionally, it would mandate that PBMs continue coverage of the drug through the end of the plan year for individuals currently using it and require advance notification of formulary changes that affect coverage. The bill also establishes a clear process for requesting formulary exceptions and mandates timely responses to such requests. Moreover, the bill would require that any denial of coverage for a nonformulary drug be communicated in writing by a licensed pharmacist or medical director, detailing the reasons for denial and the appeal process. It specifies that formulary exceptions must be approved for individuals who have previously been authorized to use a nonformulary drug, provided they meet certain criteria. These new provisions would apply to contracts entered into or renewed starting January 1, 2026, and would become effective on the general effective date of the bill.

Statutes affected:
Introduced Version: 20-3335, 20-3336
Senate Engrossed Version: 20-3335, 20-3336
Chaptered Version: 20-3335, 20-3336