Bill Text: MI SB1083 | 2013-2014 | 97th Legislature | Introduced
Bill Title: Insurance; health; prescription drugs; regulate tiered formulary. Amends 1956 PA 218 (MCL 500.100 - 500.8302) by adding sec. 3406u.
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2014-09-23 - Referred To Committee On Insurance [SB1083 Detail]
Download: Michigan-2013-SB1083-Introduced.html
SENATE BILL No. 1083
September 23, 2014, Introduced by Senator ROBERTSON and referred to the Committee on Insurance.
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
(MCL 500.100 to 500.8302) by adding section 3406u.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
Sec. 3406u. (1) An insurer that delivers, issues for delivery,
or renews in this state an expense-incurred hospital, medical, or
surgical policy or certificate or a health maintenance organization
that issues or renews a group or individual policy contract in this
state shall comply with all of the following if the coverage for
prescription drugs includes a tiered formulary:
(a) Any required out-of-pocket expenditure applicable to a
single drug shall not exceed $100.00 for up to a 30-day supply.
(b) The annual out-of-pocket expenditure for prescription
drugs shall not exceed 50% of the dollar amounts in effect under
section 223(c)(2)(A)(ii) of the internal revenue code, 26 USC
223(c)(2)(A)(ii), for self-only or family coverage.
(c) An exceptions process must be available for a covered
individual or the covered individual's prescriber to request that a
nonformulary drug be covered in the same manner as a formulary drug
if the prescriber determines that the formulary drug for treatment
of the individual's condition either would not be as effective for
the individual, or would have adverse effects for the individual,
or both. If the insurer or health maintenance organization denies
the requested exception, both of the following apply:
(i) The denial is considered an adverse event.
(ii) The denial is subject to the insurer's or health
maintenance organization's internal review process and the state
external review process.
(2) This section does not require an insurer or a health
maintenance organization to do any of the following:
(a) Provide coverage for any additional drugs not otherwise
required by law.
(b) Stop using tiered cost-sharing structures, including
strategies used to encourage use of preventive services, disease
management, or low-cost treatment options.
(3) The director of the department of financial and insurance
services may adopt rules under the administrative procedures act of
1969, 1969 PA 306, MCL 24.201 to 24.328, to implement this section.
(5) As used in this section:
(a) "Out-of-pocket expenditure" means a copayment,
coinsurance, deductible, or another cost-sharing mechanism.
(b) "Tiered formulary" means a formulary that provides
coverage for prescription drugs as part of a health plan for which
a covered individual's out-of-pocket expenditure obligations are
determined by category or tier of prescription drugs, and that
includes 2 or more different tiers.
Enacting section 1. This amendatory act applies to policies,
certificates, and contracts delivered, executed, issued, amended,
adjusted, or renewed by an insurer or a health maintenance
organization under this part, beginning 180 days after the date
this amendatory act is enacted into law.
