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This entry was published on 2022-03-04
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SECTION 4909
Prescription drug formulary changes
Public Health (PBH) CHAPTER 45, ARTICLE 49, TITLE 1
* § 4909. Prescription drug formulary changes. 1. Except as otherwise
provided in subdivision three of this section, a health care plan shall
not:

(a) remove a prescription drug from a formulary;

(b) move a prescription drug to a tier with a larger deductible,
copayment, or coinsurance if the formulary includes two or more tiers of
benefits providing for different deductibles, copayments or coinsurance
applicable to the prescription drugs in each tier; or

(c) add utilization management restrictions to a prescription drug on
a formulary, unless such changes occur at the time of enrollment or
issuance of coverage.

2. Prohibitions provided in subdivision one of this section shall
apply beginning on the date on which open enrollment begins for a plan
year and through the end of the plan year to which such open enrollment
period applies.

3. (a) A health care plan with a formulary that includes two or more
tiers of benefits providing for different deductibles, copayments or
coinsurance applicable to prescription drugs in each tier may move a
prescription drug to a tier with a larger deductible, copayment or
coinsurance if an AB-rated generic equivalent or interchangeable
biological product for such prescription drug is added to the formulary
at the same time.

(b) A health care plan may remove a prescription drug from a formulary
if the federal Food and Drug Administration determines that such
prescription drug should be removed from the market, including new
utilization management restrictions issued pursuant to federal Food and
Drug Administration safety concerns.

(c) A health care plan with a formulary that includes two or more
tiers of benefits providing for different copayments applicable to
prescription drugs may move a prescription drug to a tier with a larger
copayment during the plan year, provided the change is not applicable to
an insured who is already receiving such prescription drug or has been
diagnosed with or presented with a condition on or prior to the start of
the plan year which is treated by such prescription drug or is a
prescription drug that is or would be part of the insured's treatment
regimen for such condition.

4. A health care plan shall provide notice to policyholders of the
intent to remove a prescription drug from a formulary or alter
deductible, copayment or coinsurance requirements in the upcoming plan
year, thirty days prior to the open enrollment period for the
consecutive plan year. Such notice of impending formulary and
deductible, copayment or coinsurance changes shall also be posted on the
plan's online formulary and in any prescription drug finder system that
the plan provides to the public.

5. The provisions of this section shall not supersede the terms of a
collective bargaining agreement, or the rights of labor representation
groups to collectively bargain changes to the formularies.

* NB Effective and Repealed January 1, 2023