SB 753

This bill prohibits certain practices relating to clinician-administered drugs

under the state's insurance unfair marketing and trade practices law. The bill

defines “clinician-administered drug” as an outpatient prescription drug, other than

a vaccine, that, due to medical necessity, cannot reasonably be self-administered by

the patient or an individual assisting the patient and is typically administered by an

authorized health care provider in a physician's office, hospital outpatient

department, or other clinical setting. Under the bill, an insurer offering a health

benefit plan, a pharmacy benefit manager, or an agent of the insurer or pharmacy

benefit manager may not do any of the following:

1. Refuse to authorize, approve, or pay a participating provider for providing

a covered clinician-administered drug and related services to an enrollee,

policyholder, or insured.

2. Condition, deny, restrict, refuse to authorize or approve, or reduce payment

to a participating provider for a covered clinician-administered drug and related

services when all criteria for medical necessity are met because the provider obtains

the drug from an entity that is not selected by the plan. Also prohibited are health

benefit plan designs that prevent participating providers from receiving

reimbursement for a covered clinician-administered drug and any related service at

an applicable rate as specified in the contract.

3. Impose coverage or benefit limitations, or require an enrollee, policyholder,

or insured to pay an additional fee, higher copay or coinsurance, second copay or

coinsurance, or penalty when obtaining a clinician-administered drug from an

authorized health care provider or pharmacy.

4. Require an enrollee, policyholder, or insured to pay an additional fee, higher

copay or coinsurance, second copay or coinsurance, or other form of a price increase

for a clinician-administered drug when the drug is not dispensed by a pharmacy or

acquired from an entity that is selected by the plan.

5. Interfere with an enrollee's, policyholder's, or insured's right to choose to

obtain a clinician-administered drug from a participating provider or pharmacy of

choice.

6. Limit or exclude coverage for a clinician-administered drug when not

dispensed by a pharmacy or acquired from an entity selected by the plan when the

drug would otherwise be covered.

7. Require a pharmacy to dispense a clinician-administered drug directly to an

enrollee, policyholder, insured, or the insured's agent with the intention that the

individual will transport the drug to a health care provider for administration.

8. Require or encourage the dispensing of a clinician-administered drug to an

enrollee, policyholder, or insured in a manner that is inconsistent with the federal

Drug Supply Chain Security Act.

9. Require that a clinician-administered drug be dispensed or administered to