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Calculation Of Contributions To Meet Cost Sharing

Concerning the calculation of contributions toward an insured's required cost sharing under a health benefit plan.
2023 Regular Session
Health Care & Health Insurance
Bill Summary

The For health benefit plans issued or renewed on or after January 1, 2025, the bill requires a health insurer or pharmacy benefit manager to include in the calculation of a covered person's contributions toward cost-sharing requirements, including any annual limitation on a covered person's out-of-pocket costs, any payments made by or on behalf of the covered person for a prescription drug if:

  • The prescription drug does not have a generic equivalent; or
  • The prescription drug has a generic equivalent but the covered person is using the brand-name drug after obtaining prior authorization, complying with a step-therapy protocol, or otherwise receiving approval from the carrier or pharmacy benefit manager.

The bill also requires a prescription drug manufacturer that offers a program that reduces or eliminates a covered person's out-of-pocket expenses for a prescription drug to offer the program for the entire plan year or the calendar year, as applicable, to which the covered person's deductible and out-of-pocket calculation applies for as long as the covered person is enrolled in the health benefit plan.

The commissioner of insurance is authorized to adopt rules necessary to implement the bill .

(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.)


Became Law


Bill Text

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