Insurance Coverage for Provider-Administered Drugs

For a covered person with a chronic, complex, rare, or life-threatening medical condition, the bill prohibits a carrier from:

• Requiring a provider-administered drug to be dispensed only by certain pharmacies or only by a pharmacy participating in the carrier's specific network pharmacies ;
• If a provider-administered drug is otherwise covered by the carrier for the covered person, limiting or excluding coverage for the drug based on the covered person's choice of pharmacy or because the drug was not dispensed by a pharmacy that participates in the carrier's network participating provider ;
• Requiring a participating provider to bill for or be reimbursed for the delivery and administration of a provider-administered drug under the pharmacy benefit instead of the medical benefit without informed, written consent of the covered person and written attestation by the covered person's participating provider that a delay in the drug's administration will not place the covered person at an increased health risk; or
• Requiring a covered person to pay additional fees, copayments, or coinsurance based on the covered person's choice of pharmacy or because the provider-administered drug was not dispensed by a pharmacy that participates in the carrier's network.

The bill also requires the reimbursement rate for covered provider-administered drugs to be at the carrier's in-network negotiated rate for participating providers. The bill appropriates $77,333 to the department of regulatory agencies from the division of insurance cash fund and 0.1 FTE to implement the bill.

(Note: Italicized words indicate new material added to the original summary; dashes through words indicate deletions from the original summary.)

(Note: This summary applies to the reengrossed version of this bill as introduced in the second house.)