HB 5939 Summary

• Prohibits insurers from removing covered prescription drugs or adding utilization management restrictions during a qualified health plan year unless specific conditions are met, including FDA safety actions, manufacturing discontinuance, or clinical necessity determinations by prescribers.

• Prohibits reclassifying drugs to more restrictive tiers or higher cost-sharing during a plan year unless exceptions apply, such as FDA safety actions, clinically accepted medical best practices, newly approved drugs with clinical advantage, or grandfathering current insureds.

• Requires insurers to provide written notice 60 days before removing drugs from formularies and allows prescribers to override formulary restrictions if they determine a drug is medically necessary.

• Permits generic substitution and biosimilar alternatives consistent with existing pharmacy law, and does not restrict adding new prescription drugs to formularies during the plan year.

• Applies throughout the entire benefit period from the start to end of the qualified health plan's deductible year.