Connecticut General Statutes 38a-591o – (Note: This section is effective January 1, 2025.) Restrictions applicable to prospective or concurrent review of certain recurring prescription drugs. Exceptions
(a) As used in this section:
Terms Used In Connecticut General Statutes 38a-591o
- Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy. See Connecticut General Statutes 38a-1
- Person: means an individual, a corporation, a partnership, a limited liability company, an association, a joint stock company, a business trust, an unincorporated organization or other legal entity. See Connecticut General Statutes 38a-1
- Policy: means any document, including attached endorsements and riders, purporting to be an enforceable contract, which memorializes in writing some or all of the terms of an insurance contract. See Connecticut General Statutes 38a-1
(1) “Brand name drug” means a drug that is produced or distributed in accordance with an original new drug application approved under 21 USC 355, as amended from time to time, but does not include a generic drug as defined in 42 C.F.R. § 447.502, as amended from time to time;
(2) “Generic drug” means (A) a prescription drug product that is marketed or distributed in accordance with an abbreviated new drug application approved under 21 USC 355, as amended from time to time, (B) a generic drug as defined in 42 C.F.R. § 447.502, as amended from time to time, or (C) a drug that entered the market before calendar year 1962 that was not originally marketed under a new prescription drug product application; and
(3) “Third-party administrator” has the same meaning as provided in section 38a-720.
(b) No health carrier shall require a prospective or concurrent review of a recurring prescription drug to directly treat any autoimmune disorder, multiple sclerosis or cancer after such health carrier has certified such prescription drug through utilization review. Nothing in this section shall require a health carrier to cover: (1) Any prescription drug to treat any autoimmune disorder, multiple sclerosis or cancer if the terms of coverage completely exclude such prescription drug from the policy‘s covered benefits; (2) a brand name drug when an equivalent generic drug is available; (3) a prescription drug that was certified through prospective or concurrent review (A) by such covered person‘s previous health carrier, or (B) under a previous employer’s fully insured health plan administered by a third-party administrator that provided coverage to such covered person.