Prescription Drug Out-of-Pocket Expense Credit

      Subject to certain exceptions Beginning on January 1, 2028, the bill requires a carrier of an individual or group health benefit plan in Colorado (plan), when calculating a covered person's overall contribution to an out-of-pocket maximum or cost-sharing requirement under the plan (contribution), to account for and credit to the covered person's contribution (contribution credit) an out-of-pocket expense that the covered person incurs by purchasing a prescription drug directly from a pharmacy , health-care provider, or direct-to-consumer platform (direct purchase of a prescription drug) . The carrier shall apply the contribution credit to the covered person's contribution to the out-of-pocket maximum or cost-sharing requirement that is applicable in the plan year in which the expense from the direct purchase of a prescription drug was incurred.

     To receive a contribution credit for an out-of-pocket expense that a covered person incurred because of a direct purchase of a prescription drug, the covered person must provide proof of payment through documentation, such as an itemized receipt or pharmacy record, that is submitted to the carrier within 90 days after making the purchase . If the covered person does not provide proof of payment, the carrier is prohibited from applying the contribution credit.

     The bill also prohibits a carrier from applying the contribution credit in certain other instances. Specifically, the carrier shall not apply the contribution credit:

• For an amount of the covered person's out-of-pocket expense from the direct purchase of a prescription drug that is greater than the amount the covered person would have incurred if they had obtained the same prescription drug in the same plan year from an in-network pharmacy and pursuant to the terms of their plan;
• If the covered person does not provide proof of payment;
• If the covered person incurred the out-of-pocket expense by purchasing a prescription drug that is not covered under the formulary of the covered person's plan, unless the carrier grants an exception is granted ; or
• If the covered person does not comply with the carrier's utilization management processes, including prior authorization and step therapy protocols required under the covered person's plan.

(Note: Italicized words indicate new material added to the original summary; dashes through words indicate deletions from the original summary.)


(Note: This summary applies to the reengrossed version of this bill as introduced in the second house.)