1
2
3
4
5
6 Cosponsors:
7 Kay J. Christofferson
8 James A. Dunnigan
9 Suzanne Harrison
Eric K. Hutchings
Marsha Judkins
Lee B. Perry
Marie H. Poulson
Raymond P. Ward
Christine F. Watkins
Mike Winder
10
11 LONG TITLE
12 General Description:
13 This bill creates mechanisms to increase Utahns' access to affordable insulin.
14 Highlighted Provisions:
15 This bill:
16 ▸ creates an incentive for health benefit plans to reduce the required copayments for
17 insulin;
18 ▸ directs the Insurance Department to conduct a study on insulin pricing;
19 ▸ directs the Public Employees' Benefit and Insurance Program to purchase insulin at
20 discounted prices and to create a program that allows Utahns to purchase the
21 discounted insulin;
22 ▸ increases the number of days for which an insulin prescription can be refilled; and
23 ▸ authorizes a pharmacist to refill an expired insulin prescription.
24 Money Appropriated in this Bill:
25 None
26 Other Special Clauses:
27 This bill provides a special effective date.
28 Utah Code Sections Affected:
29 AMENDS:
30 31A-22-626, as last amended by Laws of Utah 2015, Chapter 258
31 58-17b-609, as last amended by Laws of Utah 2005, Chapter 160
32 ENACTS:
33 31A-22-626.5, Utah Code Annotated 1953
34 49-20-420, Utah Code Annotated 1953
35 58-17b-608.2, Utah Code Annotated 1953
36
37 Be it enacted by the Legislature of the state of Utah:
38 Section 1. Section 31A-22-626 is amended to read:
39 31A-22-626. Coverage of diabetes.
40 (1) As used in this section[
41 (a) "Diabetes" includes individuals with:
42 [
43 [
44 [
45 (b) "High deductible health plan" means the same as that term is defined in Section
46 223(c)(2), Internal Revenue Code.
47 (c) "Lowest tier" means:
48 (i) the lowest cost tier of a health benefit plan;
49 (ii) the lowest cost-sharing level of a high deductible health plan that preserves the
50 enrollee's ability to claim tax exempt contributions from the enrollee's health savings account
51 under federal laws and regulations; or
52 (iii) a discount or other cost-savings program that has the effect of equating
53 cost-sharing of insulin to the health plan's lowest-cost tier.
54 (d) "Therapy category" means a type of insulin that is distinct from other types of
55 insulin due to a difference in onset, peak time, or duration.
56 (2) The commissioner shall establish, by rule, minimum standards of coverage for
57 diabetes for accident and health insurance policies that provide a health insurance benefit
58 before July 1, 2000.
59 (3) In making rules under Subsection (2), the commissioner shall require rules:
60 (a) with durational limits, amount limits, deductibles, and coinsurance for the treatment
61 of diabetes equitable or identical to coverage provided for the treatment of other illnesses or
62 diseases; and
63 (b) that provide coverage for:
64 (i) diabetes self-management training and patient management, including medical
65 nutrition therapy as defined by rule, provided by an accredited or certified program and referred
66 by an attending physician within the plan and consistent with the health plan provisions for
67 self-management education:
68 (A) recognized by the federal Centers for Medicare and Medicaid Services; or
69 (B) certified by the Department of Health; and
70 (ii) the following equipment, supplies, and appliances to treat diabetes when medically
71 necessary:
72 (A) blood glucose monitors, including those for the legally blind;
73 (B) test strips for blood glucose monitors;
74 (C) visual reading urine and ketone strips;
75 (D) lancets and lancet devices;
76 (E) insulin;
77 (F) injection aides, including those adaptable to meet the needs of the legally blind, and
78 infusion delivery systems;
79 (G) syringes;
80 (H) prescriptive oral agents for controlling blood glucose levels; and
81 (I) glucagon kits.
82 (4) If a health benefit plan entered into or renewed on or after January 1, 2021,
83 provides coverage for insulin for diabetes, the health benefit plan shall:
84 (a) cap the total amount that an insured is required to pay for at least one insulin in
85 each therapy category at an amount not to exceed $30 per prescription of a 30-day supply of
86 insulin for the treatment of diabetes; and
87 (b) apply the cap to an insured regardless of whether the insured has met the plan's
88 deductible.
89 (5) Subsection (4) does not apply to a health benefit plan that:
90 (a) covers at least one insulin for the treatment of diabetes in each therapy category
91 under the lowest tier of drugs; and
92 (b) does not require cost-sharing other than a co-payment of an insured before the plan
93 will cover insulin at the lowest tier.
94 (6) Subsection (4) does not apply to a health benefit plan that:
95 (a) guarantees an insured that the insured will not pay more out-of-pocket for insulin
96 the insured obtains through the health benefit plan than the insured would pay to obtain insulin
97 through the discount program described in Section 49-20-420; and
98 (b) caps the total amount that an insured is required to pay for at least one insulin in
99 each therapy category at an amount not to exceed $100 per prescription of a 30-day supply of
100 insulin for the treatment of diabetes.
101 (7) A health benefit plan that provides coverage for insulin may condition the coverage
102 of insulin at a cost-sharing method described in Subsection (4), (5), or (6) on:
103 (a) the insured's participation in wellness-related activities for diabetes;
104 (b) purchasing the insulin at an in-network pharmacy; or
105 (c) choosing an insulin from the lowest tier of the health benefit plan's formulary.
106 (8) The department may issue a waiver from the requirements described in Subsection
107 (4) to a health benefit plan if the health benefit plan can demonstrate to the department that the
108 plan provides an insured with substantially similar consumer cost reductions to those that result
109 from Subsections (4) and (5).
110 (9) The department shall annually adjust the caps described in Subsections (4)(a) and
111 (6)(b) for inflation based on an index that reflects the change in the previous year in the average
112 wholesale price of insulin sold in Utah.
113 (10) The department shall annually provide the price of insulin available under the
114 discount program described in Section 49-20-420 to a health benefit plan that adopts the
115 cost-sharing method described in Subsection (6).
116 (11) A health benefit plan entered into or renewed on or after January 1, 2021, that
117 provides coverage of insulin is not required to reimburse a participant, as that term is defined in
118 Subsection 49-20-420(1), for insulin the participant obtains through the discount program
119 described in Section 49-20-420.
120 (12) The department may request information from insurers to monitor the impact of
121 the requirements of this section on insulin prices charged by pharmaceutical manufacturers.
122 (13) The department shall classify records provided in response to the request
123 described in Subsection (12) as protected records under Title 63G, Chapter 2, Government
124 Records Access and Management Act.
125 (14) The department may not publish information submitted in response to the request
126 described in Subsection (12) in a manner that:
127 (a) makes a specific submission from a contracting insurer identifiable; or
128 (b) discloses information that is a trade secret, as defined in Section 13-24-2.
129 Section 2. Section 31A-22-626.5 is enacted to read:
130 31A-22-626.5. Affordable insulin study.
131 (1) As used in this section, "insulin" means a prescription drug that contains insulin.
132 (2) The department shall obtain funding through grants to fund a study on insulin costs.
133 (3) If the department obtains the funding described in Subsection (2), the department
134 shall, on or before October 30, 2020, complete a study on the cost of insulin manufacturing and
135 factors that determine the price of insulin.
136 (4) The department shall use public, readily available data accessible to the department
137 to conduct the study described in Subsection (3).
138 (5) The study described in Subsection (3) shall investigate:
139 (a) current and historical trend information about the wholesale acquisition cost of
140 insulin;
141 (b) the cost to produce insulin;
142 (c) explanations for increases in insulin costs;
143 (d) expenditures of drug manufacturers in marketing insulin;
144 (e) manufacturers' net profits from insulin;
145 (f) the portion of a drug manufacturers' total net profits that is composed of insulin net
146 profits;
147 (g) financial assistance currently available to individuals who use insulin through
148 patient prescription assistance programs;
149 (h) value to individuals who use insulin benefits including:
150 (i) coupons provided directly to individuals who use insulin; and
151 (ii) programs to assist individuals who use insulin in paying co-payments and
152 coinsurance;
153 (i) costs to drug manufacturers of the programs described in Subsection (5)(h);
154 (j) total value of benefits manufacturers provide in the form of rebates for insulin to
155 health plans or pharmacy benefit managers in Utah; and
156 (k) additional information that the department determines will aid the Legislature in
157 developing policy to reduce insulin prices in Utah.
158 (6) (a) On or before October 30, 2020, the department shall submit a final report on the
159 study described in Subsection (3) to the Health and Human Services Interim Committee and
160 the Business and Labor Interim Committee.
161 (b) The department's report may include recommendations on legislation for:
162 (i) increased drug pricing transparency; and
163 (ii) programs that would meaningfully reduce the cost of insulin.
164 (c) The final report shall include references to all sources of information and data used
165 in the report and study, except the department may not disclose information that is proprietary
166 or protected under state law or federal law or regulation.
167 Section 3. Section 49-20-420 is enacted to read:
168 49-20-420. Insulin discount program.
169 (1) As used in this section:
170 (a) "Diabetes" means:
171 (i) complete insulin deficiency or type 1 diabetes;
172 (ii) insulin resistant with partial insulin deficiency or type 2 diabetes; or
173 (iii) elevated blood glucose levels induced by pregnancy or gestational diabetes.
174 (b) "Discount program" means a process developed by the program that allows
175 participants to purchase insulin at a discounted, post-rebate rate.
176 (c) "Individual with diabetes" means an individual who has been diagnosed with
177 diabetes and who uses insulin to treat diabetes.
178 (d) "Insulin" means a prescription drug that contains insulin.
179 (e) "Participant" means a resident of Utah who:
180 (i) uses insulin to treat diabetes;
181 (ii) does not receive health coverage under the program; and
182 (iii) enrolls in the discount program.
183 (f) "Prescription drug" means the same as that term is defined in Section 58-17b-102.
184 (g) "Rebate" means the same as that term is defined in Section 31A-46-102.
185 (2) Notwithstanding Subsection 49-20-201(1), and for the purpose of the insulin
186 discount program only, the program shall offer an insulin discount program that allows
187 participants to purchase insulin at a discounted, post-rebate price.
188 (3) The discount program described in Subsection (2) shall:
189 (a) provide a participant with a card or electronic document that identifies the
190 participant as eligible for the discount;
191 (b) provide a participant with information about pharmacies that will honor the
192 discount;
193 (c) allow a participant to purchase insulin at a discounted, post-rebate price; and
194 (d) provide a participant with instructions to pursue a reimbursement of the purchase
195 price from the participant's health insurer.
196 (4) The discount program shall charge a price for insulin that allows the program to
197 retain only enough of any rebate for the insulin to make the state risk pool whole for providing
198 discounted insulin to participants.
199 Section 4. Section 58-17b-608.2 is enacted to read:
200 58-17b-608.2. Insulin prescriptions and diabetes supplies.
201 (1) As used in this section, "exhausted prescription" means a prescription for an insulin
202 that the patient is currently using that:
203 (a) expired no earlier than six months before the patient requests the pharmacist for a
204 refill; or
205 (b) is not expired and has no refills remaining.
206 (2) If a valid prescription for insulin includes an authorization for one or more refills, a
207 pharmacist may combine refills to dispense a supply for 90 days but may not exceed the total
208 supply authorized by the refills.
209 (3) Notwithstanding Section 58-17b-608 and Subsection (2), a pharmacist may, on an
210 emergency basis, dispense a refill for an exhausted prescription based on the prescribing
211 practitioner's instructions for the exhausted prescription in an amount up to a supply for 90
212 days.
213 (4) A pharmacist may dispense insulin for an exhausted prescription described in
214 Subsection (3) no more than one time per exhausted prescription.
215 (5) Before a pharmacist may dispense insulin under Subsection (3), the pharmacist
216 shall:
217 (a) attempt to contact the prescribing practitioner to inform the prescribing practitioner
218 that the patient's prescription has expired; and
219 (b) notify the patient of the outcome of the attempt described in Subsection (5)(a).
220 (6) Within 30 days after the day on which a pharmacist dispenses insulin under
221 Subsection (3), the pharmacist shall inform the prescribing practitioner of:
222 (a) the amount of insulin dispensed; and
223 (b) the type of insulin dispensed.
224 (7) The division, in consultation with the Board of Pharmacy and the Physicians
225 Licensing Board, shall make rules in accordance with Title 63G, Chapter 3, Utah
226 Administrative Rulemaking Act, to ensure the safe dispensing of insulin under Subsection (3).
227 (8) Notwithstanding Section 58-17b-605.5, a pharmacist, when filling a prescription
228 for insulin, may dispense an interchangeable biological product, as defined in Subsection
229 58-17b-605.5(1), except that the pharmacist may not dispense an interchangeable biological
230 product if a prescribing practitioner prohibits the substitution through a method described in
231 Subsection 58-17b-605.5(6).
232 (9) A pharmacist may dispense the therapeutic equivalent when filling a prescription
233 for:
234 (a) a glucometer;
235 (b) diabetes test strips;
236 (c) lancets; or
237 (d) syringes.
238 Section 5. Section 58-17b-609 is amended to read:
239 58-17b-609. Limitation on prescriptions and refills -- Controlled Substances Act
240 not affected -- Legend drugs.
241 (1) Except as provided in [
242 prescription for any prescription drug or device may not be dispensed after one year from the
243 date it was initiated except as otherwise provided in Chapter 37, Utah Controlled Substances
244 Act.
245 (2) [
246 refilled may not be refilled after one year from the original issue date.
247 (3) A practitioner may not be prohibited from issuing a new prescription for the same
248 drug orally, in writing, or by electronic transmission.
249 (4) Nothing in this chapter affects Chapter 37, Utah Controlled Substances Act.
250 (5) A prescription for a legend drug written by a licensed prescribing practitioner in
251 another state may be filled or refilled by a pharmacist or pharmacy intern in this state if the
252 pharmacist or pharmacy intern verifies that the prescription is valid.
253 Section 6. Effective date.
254 This bill takes effect on May 12, 2020, except that the amendments to Sections
255 31A-22-626 and 49-20-420 take effect on January 1, 2021.