HB 1504 Summary

• Caps copayments and coinsurance for specialty tier drugs at $100 per month for a single drug (up to 30-day supply) and $200 per month aggregate per enrollee across all specialty tier drugs.

• Requires health plans using tiered formularies to implement 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 determinations subject to external review under the Uniform Health Carrier External Review Act.

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

• Becomes effective November 1, 2015; the Insurance Commissioner shall promulgate enforcement regulations.