SB3395 Summary

• Caps copayments and coinsurance for specialty tier prescription drugs at $100 per month for a single drug and $200 per month in aggregate per enrollee.

• Requires health plans using tiered formularies to establish an exceptions process allowing enrollees to request preferred drug cost-sharing for non-preferred drugs if the prescribing physician determines the preferred drug would be ineffective or cause adverse effects.

• Denials of cost-sharing exceptions must be treated as adverse events subject to the health plan's internal review process.

• Prohibits health plans from placing all drugs in a given drug class on a specialty tier.

• Takes effect January 1, 2015, and does not restrict health plans' use of prior authorization, step therapy, or other utilization management techniques.