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SB 853 Prescription Drug Coverage

Introduced by Senator Wiener If a drug has been previously approved for a medical condition of the enrollee or insured and has been prescribed by a health care provider, this bill would require health insurers to continue providing the drug during the entire duration of utilization review and any appeals of utilization review. It would prohibit a health plan or insurance policy from seeking reimbursement if the final utilization review decision is to deny coverage.

POSTED: 05/21/2022

STATUS: Senate - passed to third reading


Thoughts for consideration:

· It would make it easier for patients to continue to access specialty drugs. In cases where insurers deny coverage of an expensive drug and the patient appeals the decision.

· If passed this bill would make sure patients can still get the drug while they wait the weeks or months for the appeal to be resolved.

· It is unreasonable for a patient who is having serious health problems and is in need of a certain drug to be required to wait, potentially months, for an appeal to run its course.

· Under the proposal, insurers would have to cover the cost of the drug pending appeal, and if the denial of the drug were ultimately upheld, insurers could not try to recoup the cost of covering it temporarily.


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