WEST virginia legislature
2022 regular session
House Bill 4252
By Delegates Rohrbach, Summers, Tully, D. Jeffries, G. Ward, Bates, Jennings, Worrell, Rowan, Forsht, and Fleischauer
[Originating in the Committee on Health and Human Resources; Reported on January 18, 2022]
A BILL to amend and reenact §33-59-1 of the Code of West Virginia, 1931, as amended, relating to diabetes; reducing copayments; adding coverage for devices; permitting testing equipment to be purchased without a prescription.
Be it enacted by the Legislature of West Virginia:
ARTICLE 59. REQUIRED COVERAGE FOR HEALTH INSURANCE.
§33-59-1. Cost sharing in prescription insulin drugs.
(a) Findings. –
(1) It is estimated that over 240,000 West Virginians are diagnosed and living with type 1 or type 2 diabetes and another 65,000 are undiagnosed;
(2) Every West Virginian with type 1 diabetes and many with type 2 diabetes rely on daily doses of insulin to survive;
(3) The annual medical cost related to diabetes in West Virginia is estimated at $2.5 billion annually;
(4) Persons diagnosed with diabetes will incur medical costs approximately 2.3 times higher than persons without diabetes;
(5) The cost of insulin has increased astronomically, especially the cost of insurance copayments, which can exceed $600 per month. Similar increases in the cost of diabetic equipment and supplies, and insurance premiums have resulted in out-of-pocket costs for many West Virginia diabetics in excess of $1,000 per month;
(6) National reports indicate as many as one in four type 1 diabetics underuse, or ration, insulin due to these increased costs. Rationing insulin has resulted in nerve damage, diabetic comas, amputation, kidney damage, and even death; and
(7) It is important to enact policies to reduce the costs for West Virginians with diabetes to obtain life-saving and life-sustaining insulin.
(b) As used in this section:
(1) “Cost-sharing payment” means the total amount a covered person is required to pay at the point of sale in order to receive a prescription drug that is covered under the covered person’s health plan.
(2) “Covered person” means a policyholder, subscriber, participant, or other individual covered by a health plan.
(3) “Device” means a blood glucose test strip, glucometer, continuous glucometer, lancet, lancing device, or insulin syringe used to cure, diagnose, mitigate, prevent, or treat diabetes or low blood sugar, but does not include an insulin pump;
(3) (4) “Health plan” means any health benefit
plan, as defined in §33-16-1a(h) of this code, that provides coverage for a
prescription insulin drug.
(5) “Insulin pump” means a portable device that injects insulin at programmed intervals in order to regulate blood sugar levels in people with diabetes.
(4) (6) “Pharmacy benefits manager” means an
entity that engages in the administration or management of prescription drug
benefits provided by an insurer for the benefit of its covered persons. (5) (7) “Prescription insulin drug” means a
prescription drug that contains insulin and is used to treat diabetes.
(c) Each health plan shall cover at least one type of insulin in all the following categories:
(5) Pre-mixed insulin products;
(6) Pre-mixed insulin/GLP-1 RA products; and
(7) Concentrated human regular insulin.
(d) Notwithstanding the
provisions of §33-1-1 et seq. of this code, an insurer subject to
§33-15-1 et seq., §33-16-1 et seq., §33-24-1 et seq.,
§33-25-1 et seq., and §33-25A-1 et seq. of this code which issues
or renews a health insurance policy on or after
July 1, 2020 January
1, 2023, shall provide coverage for prescription insulin drugs
pursuant to this section.
(e) (1) Cost sharing
for a 30-day supply of a covered prescription insulin drug
not exceed $100 $35 for a 30-day supply of a covered prescription
insulin, regardless of the quantity or type of prescription insulin used to
fill the covered person’s prescription needs.
(2) Cost sharing for a device may not exceed $100 for a 30-day supply;
(3) Cost sharing for insulin pump may not exceed $250, and limited to one insulin pump purchase every 2 years.
(f) Nothing in this section prevents an insurer from reducing a covered person’s cost sharing to an amount less than the amount specified in subsection (e) of this section.
(g) No contract between an
insurer subject to §33-15-1 et seq., §33-16-1 et seq., §33-24-1 et
seq., §33-25-1 et seq., and §33-25A-1 of this code or its pharmacy
benefits manager and a pharmacy or its contracting agent shall contain a
provision: (i) Authorizing the insurer’s pharmacy benefits manager or the
pharmacy to charge; (ii) requiring the pharmacy to collect; or (iii) requiring
a covered person to make a cost-sharing payment for a covered prescription
insulin drug in an amount that exceeds the amount of the cost-sharing payment
for the covered prescription insulin drug established by the insurer pursuant
to subsection (e) of this
(h) An insurer subject to §33-15-1 et seq., §33-16-1 et seq., §33-24-1 et seq., §33-25-1 et seq., and §33-25A-1 of this code shall provide coverage for the following equipment and supplies for the treatment and/or management of diabetes for both insulin-dependent and noninsulin-dependent persons with diabetes and those with gestational diabetes: Blood glucose monitors, monitor supplies, insulin, injection aids, syringes, insulin infusion devices, pharmacological agents for controlling blood sugar, and orthotics.
(i) An insurer subject to §33-15-1 et seq., §33-16-1 et seq., §33-24-1 et seq., §33-25-1 et seq., and §33-25A-1 of this code shall include coverage for diabetes self-management education to ensure that persons with diabetes are educated as to the proper self-management and treatment of their diabetes, including information on proper diets.
(j) All health care plans
must offer an appeals process for persons who are not able to take one or more
of the offered prescription insulin drugs noted in subsection (c) of this
section. The appeals process shall be provided to covered persons in
writing and afford covered persons and their health care providers a meaningful
opportunity to participate with covered persons health care providers.
(k) Diabetes self-management education shall be provided by a health care practitioner who has been appropriately trained. The Secretary of the Department of Health and Human Resources shall promulgate legislative rules to implement training requirements and procedures necessary to fulfill provisions of this subsection: Provided, That any rules promulgated by the secretary shall be done after consultation with the Coalition for Diabetes Management, as established in §16-5Z-1 et seq. of this code.
(l) A pharmacy benefits
manager, a health plan, or any other third party that reimburses a pharmacy for
drugs or services shall not reimburse a pharmacy at a lower rate and
may not assess any fee, charge-back, or adjustment upon a pharmacy on
the basis that a covered person’s costs sharing is being impacted.
(m) A prescription is not required to obtain blood testing kit for ketones.
NOTE: The purpose of this bill is to reduce the copay cap on insulin and devices.
Strike-throughs indicate language that would be stricken from a heading or the present law and underscoring indicates new language that would be added.