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Bill Summary · SB 211

Overview

SB 211 (2026 Regular Session, Kentucky) aims to reform prescription drug coverage within state health plans by prioritizing lower-cost alternatives (generics and biosimilars) and clarifying formulary practices. The measure creates new provisions governing how health plans must handle generic drugs and biosimilars on formularies, and it expands related requirements for state employee health insurance programs and certain other plans.

Main purpose and intent

  • Reduce drug costs for state-sponsored health plans by ensuring cheaper equivalents (generics and biosimilars) are promptly added to formularies with favorable cost-sharing.
  • Prevent unnecessary barriers to accessing lower-cost drugs (e.g., prior authorizations, step therapy) when a cheaper alternative exists.
  • Establish procedural groundwork for state employee health insurance purchasing, data reporting, and governance to support these coverage requirements.

Key provisions and changes

  • Definitions (Section 1):
    • Clarifies terms for biosimilars, brand drugs, generics, reference listed drugs/products, formulary, health plan, and wholesale acquisition cost.
  • Generic drugs (Section 1, subsections 2):
    • If a generic’s wholesale cost is below the reference listed drug’s cost on the generic’s initial marketing date, the health plan must:
    • Immediately include the generic on formularies with more favorable cost-sharing.
    • Not impose prior authorization, step therapy, or other limitations that would hinder access to the generic.
  • Biosimilars (Section 1, subsections 3):
    • If a biosimilar’s wholesale cost is below the reference product’s cost on the biosimilar’s initial marketing date, the health plan must:
    • Immediately include at least one biosimilar on formulary with more favorable cost-sharing.
    • Not impose prior authorizations, step therapy, or access restrictions for the biosimilar compared to the reference product.
  • General formulary protections (Section 1, subsection 4):
    • This section clarifies that requirements do not force continued coverage of a brand/generic/biosimilar if medical appropriateness or cost-effectiveness no longer supports it.
    • Does not interfere with pharmacist compliance with existing Kentucky pharmacy laws.
  • Limited health service benefit plans (Section 2) and broader applicability (Section 4):
    • Aligns with existing Kentucky health plan statutes, ensuring SB 211’s provisions apply to limited health service benefit plans and public employee health plans.
  • State health insurance program governance (Section 4):
    • Requires the Finance and Administration and Personnel Cabinets to procure and administer a group health benefit plan, with bid processes, data reporting, and confidentiality protections.
    • Mandates data ownership by the Commonwealth, annual reporting on financial stability, loss ratios, risk adjustment, and cost-management metrics.
    • Specifies enrollment options, self-insurance possibilities, and open enrollment mechanics.
    • Includes a mail-order option for maintenance drugs and protections for retail pharmacies meeting plan terms.
  • Additional coverage mandates (Sections 4 and 4(14)-(16)):
    • Includes coverage for hearing aids (with caps), autism spectrum disorders, and amino acid-based elemental formula for eligible individuals.
  • Special enrollment rights (Section 4(13)):
    • Requires special enrollment periods for pregnant women eligible for coverage, with notice provided to employees.

Who is affected

  • State employees and their dependents enrolled in the state-sponsored health insurance program.
  • Public postsecondary institutions and their employees (self-insured or fully insured plans under the state system).
  • Carriers and third-party administrators offering state health coverage (subject to bid and data-reporting requirements).
  • Pharmacists and pharmacies operating within the plan’s geographic coverage areas (protections against discrimination in mail-order and access).

Procedural and timeline aspects

  • Effective date: January 1, 2027 for health plans issued or renewed to which SB 211 applies.
  • Section 5 and 6 establish the act’s applicability and effective date.
  • Requires a 32-member Advisory Committee of State Health Insurance Subscribers to advise on the program (annual appointment in January; quarterly meetings).

Potential impact

  • Increased availability and faster adoption of lower-cost generics and biosimilars on state formularies.
  • Reduced out-of-pocket costs for beneficiaries when cheaper alternatives exist.
  • Greater transparency and oversight of the state health insurance program through data reporting and annual financial analyses.
  • Expanded coverage of certain therapies and devices (hearing aids, autism therapies, specialized formulas) for state employees and dependents.

Compiled from official sources — confirm details with the bill’s official record.

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