HOUSE BILL NO. 5721
April 24, 2020, Introduced by Rep. Sheppard and
referred to the Committee on Government Operations.
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
by amending section 3406o (MCL 500.3406o), as amended by 2016 PA 276, and by adding section 3406v.
the people of the state of michigan enact:
Sec. 3406o. (1) An insurer that delivers, issues for
delivery, or renews in this state a health insurance policy that provides
coverage for prescription drugs and limits those benefits to drugs included in
a formulary shall do all of the following:
(a) Provide for
participation of participating physicians, dentists, and pharmacists in the development
of the formulary.
(b) Disclose to health
care providers and upon request to insureds the nature of the formulary
restrictions.
(c) Provide for
exceptions from the formulary limitation when a nonformulary alternative is a
medically necessary and appropriate alternative. This subdivision does not
prevent an insurer from establishing prior authorization requirements or
another process for consideration of coverage or higher cost-sharing for
nonformulary alternatives.
(2) On a request for an
expedited review of coverage for a nonformulary alternative based on exigent
circumstances, an insurer shall make a determination and notify the enrollee or
the enrollee's designee and the prescribing physician, or other prescriber, as
appropriate, of the determination within 24 hours after the insurer receives
all information necessary to determine whether the exception should be granted.
For purposes of this subsection, exigent circumstances exist when an enrollee
is suffering from a health condition that may seriously jeopardize the
enrollee's life, health, or ability to regain maximum function or when an
enrollee is undergoing a current course of treatment using a nonformulary drug.
(3) If subsection (2)
does not apply, an insurer shall make a determination on coverage for a
nonformulary alternative and notify the enrollee or the enrollee's designee and
the prescribing physician, or other prescriber, as appropriate, of the
determination within 72 hours after the insurer receives all information
necessary to determine whether the exception should be granted.
(4) This section is subject to section 3406v.
Sec. 3406v. During the state of emergency declared under Executive
Order No. 2020-4 or any extension of that order, an insurer that delivers,
issues for delivery, or renews in this state a health insurance policy that
provides coverage for prescription drugs shall do both of the following:
(a) Provide
coverage for an emergency refill of up to a 60-day supply of any noncontrolled
maintenance medication.
(b) Provide coverage for an early refill of any 30-day or 60-day prescription maintenance drug to allow for up to a 90-day supply, without regard to whether the pharmacy is mail order or in person.