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Bill

H 4795

Pharmacy Benefits Manager drug modifications

2025-2026 Regular Session Introduced by Brandon Cox and 11 co-sponsors

Health benefit plan issuers must provide at least 60 days’ advance uniform notice to regulators, sponsors, and enrollees before any renewal-time drug-coverage changes.

Member(s) request name added as sponsor: Crawford
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Bill Summary · H 4795

Summary of Bill H. 4795 (2025-2026) — South Carolina

Purpose and Intent

  • The bill adds a new section to the South Carolina Code to regulate how health benefit plan issuers (pharmacy benefits managers, or PBMs, and related health plan sponsors) modify drug coverage.
  • The core aim is to ensure advance, uniform notice and non-coercive options when changes to drug coverage are made, particularly at renewal.

What the bill would do (key provisions)

Section 38-71-2247: Drug Coverage Modifications

  1. Timing of Modifications

    • A health benefit plan issuer may modify drug coverage at the time of coverage renewal.

  2. Uniformity of Modification

    • The modification must be effective uniformly across:
      • All group health benefit plan sponsors with identical or substantially identical plans, or
      • All individuals under identical or substantially identical individual health benefit plans, as applicable.

  3. Notice Requirements

    • At least 60 days before the modification becomes effective, the issuer must provide written notice to:
      • The South Carolina Insurance Commissioner
      • Each affected group health benefit plan sponsor
      • Each affected enrollee in an affected group health benefit plan
      • Each affected individual health benefit plan holder

  4. Types of Modifications Requiring Notice

    • The following drug-coverage actions require notice under subsection (A):
      • Removal of a drug from a formulary
      • Introduction of a requirement for prior authorization for a drug
      • Imposition or alteration of a quantity limit for a drug
      • Imposition of a step-therapy restriction for a drug
      • Moving a drug to a higher cost-sharing tier unless a generic alternative is available

  5. Enrollee Notification Option

    • An enrollee may opt to receive the required notices by email, if the plan offers this option.

  6. Waiver Rights

    • A patient may knowingly and voluntarily waive the protections provided under this section.
    • Waivers cannot be induced or coerced; any violation of this right renders the waiver void.

Who would be affected

  • Health benefit plan issuers (including PBMs acting in the capacity of managing drug coverage)
  • Group health benefit plan sponsors (employers or other entities sponsoring group plans)
  • Individual health benefit plan holders and enrollees (individual market plans)
  • The South Carolina Insurance Commissioner would receive required notices of modifications.

Procedural and Timeline Details

  • Effective date Timing: Changes to drug coverage must occur at renewal and be applied uniformly.
  • Notice window: Minimum 60 days’ written notice prior to the effective date.
  • Notice recipients: Commissioner, affected sponsors, and affected enrollees/individual plan holders.
  • Notice method option: Email notification available at the issuer’s discretion for enrollees.
  • Waivers: Explicit allowance for voluntary waivers by patients, with anti-coercion protections and void waivers if coercion is found.

Practical Implications and Potential Impacts

  • The bill increases transparency around formulary changes and prior authorization/step-therapy requirements.
  • It provides a predictable notice period, enabling sponsors and enrollees to adjust plans, review alternatives, or appeal changes.
  • By requiring uniform application across similar plans, it aims to prevent selective or inconsistent formulary changes.
  • Email notification option may reduce administrative burden and speed communication.
  • The explicit waiver provision protects patient autonomy but requires safeguards to prevent pressure or coercion.

Summary

H. 4795 would require health benefit plan issuers to provide at least 60 days’ advance written notice to regulators, sponsors, and enrollees before modifying drug coverage at renewal, with changes applied uniformly across similar plans. It lists specific drug-coverage modifications that trigger notice and allows voluntary email notices and patient waivers (with protections against coercion). The measure seeks greater transparency and consistency in formulary changes and associated patient protections.

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

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