SENATE BILL 536
50th legislature - STATE OF NEW MEXICO - first session, 2011
INTRODUCED BY
Timothy Z. Jennings
AN ACT
RELATING TO HEALTH INSURANCE; AMENDING SECTIONS OF THE NEW MEXICO INSURANCE CODE, THE HEALTH MAINTENANCE ORGANIZATION LAW AND THE NONPROFIT HEALTH CARE PLAN LAW TO IMPOSE PRICING CONTROLS ON CERTAIN TYPES OF PRESCRIPTION DRUGS; PROVIDING FOR CONTINGENT APPLICABILITY.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
SECTION 1. A new section of Chapter 59A, Article 22 NMSA 1978 is enacted to read:
"[NEW MATERIAL] PRESCRIPTION DRUG PRICE CONTROLS.-- A. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in this state that provides coverage for prescription drugs and for which cost-sharing, deductibles or co-insurance obligations are determined by the category or "tier" of the prescription drug shall not impose cost-sharing, deductibles or co-insurance obligations for any prescription drug that exceeds the dollar amount of cost-sharing, deductibles or other co-insurance obligations for:
(1) a non-preferred brand drug or its equivalent; or
(2) a brand drug if there is no non-preferred brand drug category.
B. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in this state that provides coverage for prescription drugs and for which cost-sharing, deductibles or co-insurance obligations are determined by the category or "tier" of the prescription drug shall not reclassify drugs that are on a tier 4 or 5 to a higher tier of the formulary during the term of the evidence of coverage. When a drug is reclassified to a higher category or tier, the administrator for the plan shall give the enrollee sixty days' advance notice of the impending change.
C. The provisions of this section shall not apply in the event that federal law requires the state to make payments on behalf of enrollees to cover the costs of implementing this section."
SECTION 2. A new section of Chapter 59A, Article 23 NMSA 1978 is enacted to read:
"[NEW MATERIAL] PRESCRIPTION DRUG PRICE CONTROLS.--
A. A blanket or group health insurance policy or contract that is delivered, issued for delivery or renewed in this state that provides coverage for prescription drugs and for which cost-sharing, deductibles or co-insurance obligations are determined by the category or "tier" of the prescription drug shall not impose cost-sharing, deductibles or co-insurance obligations for any prescription drug that exceeds the dollar amount of cost-sharing, deductibles or other co-insurance obligations for:
(1) a non-preferred brand drug or its equivalent; or
(2) a brand drug if there is no non-preferred brand drug category.
B. A blanket or group health insurance policy or contract that is delivered, issued for delivery or renewed in this state that provides coverage for prescription drugs and for which cost-sharing, deductibles or co-insurance obligations are determined by the category or "tier" of the prescription drug shall not reclassify drugs that are on a tier 4 or 5 to a higher tier of the formulary during the term of the evidence of coverage. When a drug is reclassified to a higher category or tier, the administrator for the plan shall give the enrollee sixty days' advance notice of the impending change.
C. The provisions of this section shall not apply in the event that federal law requires the state to make payments on behalf of enrollees to cover the costs of implementing this section."
SECTION 3. A new section of the Health Maintenance Organization Law is enacted to read:
"[NEW MATERIAL] PRESCRIPTION DRUG COST CONTROLS.--
A. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state that provides coverage for prescription drugs and for which cost-sharing, deductibles or co-insurance obligations are determined by the category or "tier" of the prescription drug shall not impose cost-sharing, deductibles or co-insurance obligations for any prescription drug that exceeds the dollar amount of cost-sharing, deductibles or other co-insurance obligations for:
(1) a non-preferred brand drug or its equivalent; or
(2) a brand drug if there is no non-preferred brand drug category.
B. An individual or group health maintenance organization contract that is delivered, issued for delivery or renewed in this state that provides coverage for prescription drugs and for which cost-sharing, deductibles or co-insurance obligations are determined by the category or "tier" of the prescription drug shall not reclassify drugs that are on a tier 4 or 5 to a higher tier of the formulary during the term of the evidence of coverage. When a drug is reclassified to a higher category or tier, the administrator for the plan shall give the enrollee sixty days' advance notice of the impending change.
C. The provisions of this section shall not apply in the event that federal law requires the state to make payments on behalf of enrollees to cover the costs of implementing this section."
SECTION 4. A new section of the Nonprofit Health Care Plan Law is enacted to read:
"[NEW MATERIAL] PRESCRIPTION DRUG PRICE CONTROLS.--
A. An individual or group health insurance policy, health care plan or certificate of health insurance delivered or issued for delivery in this state that is delivered, issued for delivery or renewed in this state that provides coverage for prescription drugs and for which cost-sharing, deductibles or co-insurance obligations are determined by the category or "tier" of the prescription drug shall not impose cost-sharing, deductibles or co-insurance obligations for any prescription drug that exceeds the dollar amount of cost-sharing, deductibles or other co-insurance obligations for:
(1) a non-preferred brand drug or its equivalent; or
(2) a brand drug if there is no non-preferred brand drug category.
B. An individual or group health insurance policy, health care plan or certificate of health insurance that is delivered, issued for delivery or renewed in this state that provides coverage for prescription drugs and for which cost-sharing, deductibles or co-insurance obligations are determined by the category or "tier" of the prescription drug shall not reclassify drugs that are on a tier 4 or 5 to a higher tier of the formulary during the term of the evidence of coverage. When a drug is reclassified to a higher category or tier, the administrator for the plan shall give the enrollee sixty days' advance notice of the impending change.
C. The provisions of this section shall not apply in the event that federal law requires the state to make payments on behalf of enrollees to cover the costs of implementing this section."
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