HOUSE BILL NO. 5339
"The insurance code of 1956,"
by amending section 3406t (MCL 500.3406t), as added by 2016 PA 38.
the people of the state of michigan enact:
Sec. 3406t. (1) An insurer that delivers, issues for delivery, or renews in this state an expense-incurred hospital, medical, or surgical group or individual a health insurance policy or certificate that provides prescription drug coverage , or a health maintenance organization that offers a group or individual contract that provides prescription drug coverage, shall provide a program for synchronizing multiple maintenance prescription drugs for an insured or enrollee if both of the following are met:
(a) The insured or enrollee, the insured's or enrollee's physician, and a pharmacist agree that synchronizing the insured's or enrollee's multiple maintenance prescription drugs for the treatment of a chronic long-term care condition is in the best interests of the insured or enrollee for the management or treatment of a chronic long-term care condition.
(b) The insured's or enrollee's multiple maintenance prescription drugs meet all of the following requirements:
(i) Are covered by the health insurance policy , certificate, or contract described in this section.
(ii) Are used for the management and treatment of a chronic long-term care condition and have authorized refills that remain available to the insured or enrollee.
(iii) Except as otherwise provided in this subparagraph, are not controlled substances included in schedules 2 to 5 under sections 7214, 7216, 7218, and 7220 of the public health code, 1978 PA 368, MCL 333.7214, 333.7216, 333.7218, and 333.7220. This subparagraph does not apply to anti-epileptic prescription drugs.
(iv) Meet all prior authorization requirements specific to the maintenance prescription drugs at the time of the request to synchronize the insured's or enrollee's multiple maintenance prescription drugs.
(v) Are of a formulation that can be effectively split over required short fill periods to achieve synchronization.
(vi) Do not have quantity limits or dose optimization criteria or requirements that will be violated when synchronizing the insured's or enrollee's multiple maintenance prescription drugs.
(2) An insurer or health maintenance organization described in subsection (1) shall apply a prorated daily cost-sharing rate for maintenance prescription drugs that are dispensed by an in-network pharmacy for the purpose of synchronizing the insured's or enrollee's multiple maintenance prescription drugs.
(3) An insurer or health maintenance organization described in subsection (1) shall not reimburse or pay any dispensing fee that is prorated. The insurer or health maintenance organization shall only pay or reimburse a dispensing fee that is based on each maintenance prescription drug dispensed.
(4) If an insurer described in subsection (1) or a utilization review organization implements a step therapy protocol, an insurer or utilization review organization shall do both of the following:
(a) Implement protocol via clinical review criteria that are based on clinical practice guidelines to which all of the following apply:
(i) The guidelines recommend that the prescription drugs be taken in the specific sequence required by the step therapy protocol.
(ii) Subject to subparagraph (vi), the guidelines are developed and endorsed by a multidisciplinary panel of experts that manages conflicts of interest among the members of the writing and review groups by doing all of the following:
(A) Requiring members to disclose any potential conflict of interests with entities, including insurers, health plans, and pharmaceutical manufacturers and recuse themselves from voting if they have a conflict of interest.
(B) Using a methodologist to work with writing groups to provide objectivity in data analysis and ranking evidence through the preparation of evidence tables and facilitating consensus.
(C) Offering opportunities for public review and comments.
(iii) The guidelines are based on high-quality studies, research, and medical practice.
(iv) The guidelines are created by an explicit and transparent process that does all of the following:
(A) Minimizes biases and conflicts of interest.
(B) Explains the relationship between treatment options and outcomes.
(C) Rates the quality of the evidence supporting recommendations.