Nonmedical Switching Enacted Laws


California:

  • Requires health plans to provide coverage for medically necessary treatments, even if those treatments are non-formulary.¹

1: https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160AB339


Illinois

  • Prohibits health plans from rescinding coverage for a medication in the middle of a plan year unless it provides 60 days’ advance notice to the enrollees who are currently receiving that medication and providers who are prescribing it. Allows providers to override the coverage rescission by attesting to the medical necessity of the medication.¹

1: http://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=100-1052


Indiana

  • Prohibits health plans from removing a treatment from the formulary, changing the cost-sharing requirements that apply to a treatment, or changing the utilization review requirements that apply to a treatment, unless the plan provides written notice to all patients who were prescribed the treatment in the past 12 month period at least 60 days in advance of the formulary change. Alternatively, health plans may dispense a 60-day supply of the treatment to affected enrollees.¹

1: http://iga.in.gov/legislative/2016/bills/senate/41#document-d46dfac7


Louisiana

  • Requires health plans to provide coverage of the medications listed on their formulary through the duration of the plan year, regardless of whether coverage was rescinded in the middle of the plan year.¹

1: http://www.legis.la.gov/legis/ViewDocument.aspx?d=762663

Maine

  • Requires health plans to provide an exceptions process for formulary limitations.1
  • Requires health plans to provide 60 days’ advance notice to plan enrollees before making an adverse change to their formularies.¹
  • Requires health plans to notify all affected enrollees before removing a treatment from their formulary. This notice must include information for requesting an exception from the formulary change.¹

1: https://legislature.maine.gov/legis/bills/getPDF.asp?paper=HP0487&item=3&snum=128


Maryland

  • Requires health plans to publish and implement a procedure whereby an enrollee can receive coverage of a treatment that was excluded from the plan’s formulary or removed from the formulary in the middle of the plan year.¹
  • Requires health plans to publish and implement a procedure whereby an enrollee can receive continued coverage of a treatment at the same cost-sharing level if the treatment was moved to a higher cost-sharing tier in the middle of the plan year.¹
  • Requires health plans to provide 30 days’ advance notice to all affected enrollees and their prescribers before removing a treatment from the formulary or moving it to a higher cost-sharing tier. This notice must include information for requesting an exemption from the formulary change.¹

1: https://legiscan.com/MD/text/SB405/2019


Nevada

  • Prohibits health plans from removing a treatment from the formulary in the middle of the plan year except for concerns about product safety.¹
  • Prohibits health plans from moving a medication to a higher cost-sharing tier unless it is done in combination with including coverage for a generic alternative at an equal or lower cost-sharing tier than the product was originally covered at.¹

1: https://www.leg.state.nv.us/register/2014Register/R074-14A.pdf


New Mexico

  • Prohibits health plans from making an adverse change to coverage of a treatment included in the plan’s formulary within 120 days of making an adverse change to coverage of that same treatment.1
  • Requires health plans to provide affected enrollees with 60 days’ advance notice before making an adverse change to coverage of a treatment on the plan’s formulary.¹

1: https://law.justia.com/codes/new-mexico/2014/chapter-59a/article-22/section-59a-22-49.4


Rhode Island

  • Requires health plans to provide affected enrollees and their prescribers with 30 days’ advance notice before making an adverse change to coverage of a treatment on the plan’s formulary. This notice must include information for requesting an exception from the formulary change.¹

1: https://law.justia.com/codes/rhode-island/2017/title-27/chapter-27-18/section-27-18-50/


Texas

  • Requires health plans to provide coverage of any treatment for chronic, disabling, or life-threatening conditions.¹
  • Requires formulary coverage changes to only be made during coverage renewal.¹
  • Requires health plans to provide affected enrollees with 30 days’ advance notice before making an adverse change to coverage of a treatment on the plan’s formulary.¹

1: https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1369.htm