Vermont Statutes-Title 8-Chapter 107-Subchapter 10. Prescription Drug Coverage

See the bold text below:

Section 4091. Definitions.

As used in this subchapter: 

(1) “Direct solicitation” means direct contact, including telephone, computer, email, instant messaging, or in-person contact, by a pharmacy provider or its agent to an individual covered under a health insurance plan without the covered individual’s consent for the purpose of marketing the pharmacy provider’s services. 

(2) “Health care professional” means an individual licensed to practice medicine under 26 V.S.A. chapter 23 or 33, an individual licensed as a physician assistant under 26 V.S.A. chapter 31, or an individual licensed as an advanced practice registered nurse under 26 V.S.A. chapter 28.

(3) “Health insurance plan” has the same meaning as in section 4011 of this chapter and includes prescription drug benefits managed by a health insurer or by a pharmacy benefit manager on behalf of a health insurer. 

(4) “Interchangeable biological products” has the same meaning as in 18 V.S.A. § 4601. 

(5) “Out-of-pocket expenditure” means a co-payment, coinsurance, deductible, or other cost-sharing mechanism. 

(6) “Pharmacy benefit manager” means an entity that performs pharmacy benefit management.  “Pharmacy benefit management” means an arrangement for the procurement of prescription drugs at negotiated dispensing rates, the administration or management of prescription drug benefits provided by a health insurance plan for the benefit of beneficiaries, or any of the following services provided with regard to the administration of pharmacy benefits: 

(A) mail service pharmacy; 

(B) claims processing, retail network management, and payment of claims to pharmacies for prescription drugs dispensed to beneficiaries; 

(C) clinical formulary development and management services; 

(D) rebate contracting and administration; 

(E) certain patient compliance, therapeutic intervention, and generic substitution programs; and 

(F) disease management programs. 

(7) “Pharmacy benefit manager affiliate” means a pharmacy or pharmacist that, directly or indirectly, through one or more intermediaries, is owned or controlled by, or is under common ownership or control with, a pharmacy benefit manager. 

(8) “Prescription drug” or “drug” has the same meaning as “prescription drug” in 26 V.S.A. § 2022 and includes: 

(A) biological products, as defined in 18 V.S.A. § 4601; 

(B) medications used to treat complex, chronic conditions, including medications that require administration, infusion, or injection by a health care professional; 

(C) medications for which the manufacturer or the U.S. Food and Drug Administration requires exclusive, restricted, or limited distribution; and 

(D) medications with specialized handling, storage, or inventory reporting requirements. 

(9) “Prescription insulin medication” means a prescription drug that contains insulin and is used to treat diabetes. 

Step Therapy Override

(10) “Step therapy” means protocols that establish the specific sequence in which prescription drugs for a specific medical condition are to be prescribed.

Section 4092. Prescription Drug Coverage

(a)  A health insurance plan shall not include an annual dollar limit on prescription drug benefits.

(b)  A health insurance plan shall limit a covered individual’s out-of-pocket expenditures for all prescription drugs to not more for self-only and family coverage per year than the minimum dollar amounts in effect under Section 223(c)(2)(A)(i) of the Internal Revenue Code of 1986 for self-only and family coverage, respectively. 

(c)(1)  For prescription drug benefits offered in conjunction with a high deductible health plan (HDHP), the plan shall not provide prescription drug benefits until the expenditures applicable to the deductible under the HDHP have met the amount of the minimum annual deductibles in effect for self-only and family coverage under Section 223(c)(2)(A)(i) of the Internal Revenue Code of 1986 for self-only and family coverage, respectively, except that a plan may offer first-dollar prescription drug benefits to the extent permitted under federal law.   

(2) Once the applicable expenditure amount set forth in subdivision (1) of this subsection has been met under the HDHP, coverage for prescription drug benefits shall begin, and the limit on out-of-pocket expenditures for prescription drug benefits shall be as specified in subsection (b) of this section. 

Step Therapy Override

(d)(1) A health insurance plan that uses step-therapy protocols shall: 

(A) not require failure, including discontinuation due to lack of efficacy or effectiveness, diminished effect, or an adverse event, on the same drug on more than one occasion for covered individuals who are continuously enrolled in a plan offered by the health insurer or its pharmacy benefit manager; and 

(B)  grant an exception to its step-therapy protocols upon request of a covered individual or the covered individual’s treating health care professional under the same time parameters as set forth for prior authorization requests in 18 V.S.A. § 9418b(g)(4) if any one or more of the following conditions apply: 

(i)  the prescription drug required under the step-therapy protocol is contraindicated or will likely cause an adverse reaction or physical or mental harm to the covered individual; 

(ii)  the prescription drug required under the step-therapy protocol is expected to be ineffective based on the covered individual’s known clinical history, condition, and prescription drug regimen; 

(iii)  the covered individual has already tried the prescription drugs on the protocol, or other prescription drugs in the same pharmacologic class or with the same mechanism of action, which have been discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event, regardless of whether the covered individual was covered at the time on a plan offered by the current insurer or its pharmacy benefit manager; 

(iv)  the covered individual is stable on a prescription drug selected by the covered individual’s treating health care professional for the medical condition under consideration; or 

(v)  the step-therapy protocol or a prescription drug required under the protocol is not in the covered individual’s best interests because it will: 

(I)  pose a barrier to adherence; 

(II)  likely worsen a comorbid condition; or 

(III)  likely decrease the covered individual’s ability to achieve or maintain reasonable functional ability. 

(2)  Nothing in this subsection shall be construed to prohibit the use of tiered co-payments for covered individuals not subject to a step-therapy protocol. 

(3)  Notwithstanding any provision of subdivision (1) of this subsection to the contrary, a health insurance shall not utilize a step-therapy, “fail first,” or other protocol that requires documented trials of a prescription drug, including a trial documented through a “MedWatch” (FDA Form 3500), before approving a prescription for the treatment of substance use disorder. 

(e)(1)  A health insurance plan shall not require, as a condition of coverage, use of drugs not indicated by the U.S. Food and Drug Administration for the condition diagnosed and being treated under the supervision of a health care professional. 

(2)  Nothing in this subsection shall be construed to prevent a health care professional from prescribing a prescription drug for off-label use. 

(f)  A health insurance plan shall apply the same cost-sharing requirements to interchangeable biological products as apply to generic drugs under the plan. 

(g)(1)  A health insurance plan shall limit a covered individual’s total out-of-pocket responsibility for prescription insulin drugs to not more than $100.00 per 30-day supply, regardless of the amount, type, or number of insulin drugs prescribed for the covered individual. 

(2)  The $100.00 monthly limit on out-of-pocket spending for prescription insulin drugs set forth in subdivision (1) of this subsection shall apply regardless of whether the covered individual has satisfied any applicable deductible requirement under the health insurance plan. 

(h)  A health insurance plan shall cover, without requiring prior authorization, at least one readily available asthma controller drug from each class of drug and mode of administration.  As used in this subsection, “readily available” means that the medication is not listed on a national drug shortage list, including lists maintained by the U.S. Food and Drug Administration and by the American Society of Health-System Pharmacists.  

(i)  On a periodic basis but not less than once per calendar year, each health insurer shall notify all individuals covered under its health insurance plans of any changes in pharmaceutical coverage and provide access to the preferred drug list maintained by the health insurer or its pharmacy benefit manager.  

(j)  The Department of Financial Regulation shall enforce this section and may adopt rules as necessary to carry out the purposes of this section.  

(k)  A health insurance plan shall provide coverage for prescription drugs purchased in Canada and used in Canada or reimported legally on the same benefit terms and conditions as prescription drugs purchased in this country.  For drugs purchased by mail or through the internet, the plan may require accreditation by the Internet and Mailorder Pharmacy Accreditation Commission (IMPAC/tm) or similar organization.