Plain-English Summary
This legislation, titled the "Prescription Benefit Manager Accountability Act," establishes new regulations for Prescription Benefit Managers (PBMs). It mandates that PBMs must cover a specific prescribed medication without substitution or "step therapy" requirements if the prescribing doctor submits a notarized letter confirming the drug's medical necessity and the ineffectiveness of alternatives. Furthermore, the bill requires that any denial of coverage be reviewed by a licensed healthcare professional with specific expertise in that medical field. PBMs must also document the reviewer's credentials and the clinical reasons for any denial.
Sometimes, when a doctor prescribes a medicine, the company managing the insurance plan tries to swap it for a different, cheaper medicine or makes the patient try other medicines first. This bill creates a new rule. It says that if a doctor writes a special official letter promising that a specific medicine is the only one that will work for the patient, the insurance managers have to say "yes" and pay for it. They cannot force the patient to try other things. It also makes sure that only actual experts can say "no" to a medicine.