An Act To Require Health Insurance Carriers and Pharmacy Benefits Managers To Appropriately Account for Cost-sharing Amounts Paid on Behalf oflnsureds
Maine Legislature, Session 130, LD 1783
Committee Amendment CA_A_S479 (Senate)
Amends: 24-A MRSA §4349

COMMITTEE AMENDMENT "A " to S.P. 621, L.D. 1783, "An Act To Require 
Health Insurance Carriers and Pharmacy Benefits Managers To Appropriately Account for 
Cost-sharing Amounts Paid on Behalf oflnsureds" 
Amend the bill by striking out everything after the enacting clause and inserting the 
following: 
'Sec.1. 24-A MRSA §4349, sub-§6 is enacted to read: 
6. Cost-sharing amounts paid on behalf of covered person. The requirements of 
this subsection apply to the calculation of a covered person's contribution to any applicable 
cost-sharing or other out-of-pocket expense under a covered prescription drug benefit. 
A. When calculating a covered person's contribution to any applicable cost-sharing or 
other out-of-pocket expense under a covered prescription drug benefit, a carrier or 
pharmacy benefits manager shall give credit for any waiver or discount of, or payment 
made by a 3rd party for, the amount of, or any portion of the amount of, the applicable 
cost-sharing or other out-of-pocket expense for the covered prescription drug that is 
either: 
(1) Without a generic equivalent; or 
(2) With a generic equivalent when the covered person has obtained access to the 
covered prescription drug through prior authorization, a step therapy override 
exception or other exception or appeal process. 
B. A 3rd party that pays as financial assistance any amount, or portion of the amount, 
of any applicable cost-sharing or other out-of-pocket expense on behalf of a covered 
person for a covered prescription drug: 
(1) Shall notify the covered person prior to or within 7 days of the acceptance of 
the financial assistance of the total amount of assistance available and the duration 
for which it is available; and 
(2) May not condition the assistance on enrollment in a specific health plan or type 
of health plan, except as permitted under federal law. 
COMMITTEE AMENDMENT 
COMMITTEE AMENDMENT" (\-"to S.P. 621, L.D. 1783 ('5-47~ 
C. If under federal law, with respect to a high-deductible health plan offered for use 
with a health savings account in accordance with the federal Internal Revenue Code, 
the application of paragraph A would result in ineligibility for a health savings account, 
this subsection applies only with respect to the deductible of such a plan after the 
covered person has satisfied the minimum deductible under the federal Internal 
Revenue Code, Section 223, except for items or services that are determined to be 
preventive care pursuant to the federal Internal Revenue Code, Section 223(c)(2)(C), 
in which case the requirements of paragraph A apply regardless of whether the 
minimum deductible under the federal Internal Revenue Code, Section 223 has been 
satisfied. 
Sec. 2. Application. The requirements of this Act apply to prescription drug benefits 
provided pursuant to a contract or policy of insurance by a carrier or a pharmacy benefits 
manager on behalf of a carrier on or after January 1, 2023.' 
Amend the bill by relettering or renumbering any nonconsecutive Part letter or section 
number to read consecutively. 
SUMMARY 
This amendment replaces the bill with language that reflects model legislation adopted 
by the National Council of Insurance Legislators. Like the bill, the amendment requires 
health insurance carriers and their pharmacy benefits managers to include cost-sharing 
amounts paid on behalf of an insured when calculating the insured's contribution to any 
out-of-pocket maximum, deductible or copayment when a drug does not have a generic 
equivalent or was obtained through prior authorization, a step therapy override exception 
or an exception or appeal process. 
The amendment adds a requirement that a person who pays any amount on behalf of a 
covered person for a covered prescription drug must notify the covered person prior to or 
within 7 days of the acceptance of the financial assistance of the total amount of assistance 
available and the duration for which it is available and prohibits the conditioning of the 
assistance on enrollment in a specific health plan or type of health plan. The amendment 
also adds language providing an exception when application of the requirements to a person 
who has a health savings account would result in ineligibility for that health savings account 
under federal law except for items or services that are determined to be preventive care. 
As in the bill, the requirements apply to prescription drug benefits provided pursuant 
to a contract or policy of insurance by a carrier or a pharmacy benefits manager on behalf 
of a carrier on or after January 1, 2023. 
FISCAL NOTE REQUIRED 
(See attached) 
COMMITTEE AMENDMENT 
Approved: 03/24/22 ;:k?ae 
LD 1783 
LR2363(02) 
An Act To Require Health Insurance Carriers and Pharmacy Benefits Managers To Appropriately 
Account for Cost-sharing Amounts Paid on Behalf of Insureds 
Fiscal Detail and Notes 
Fiscal Note for Bill as Amended by Committee Amendment 'it' CS- Y7 q) 
Committee: Health Coverage, Insurance and Financial Services 
Fiscal Note Required: Yes 
Fiscal Note 
Potential future biennium cost increase - General Fund 
Requiring the inclusion of certain cost sharing amounts made on behalf of participants in a covered prescription drug 
benefit be included in the calculation of plan out-of-pocket maximums, deductibles and copayments could result in an 
increase in costs to the State Employee Health Plan beginning in the plan year starting July 1, 2023. The amount and 
timing of the additional costs will depend on the volume of such payments (e.g., manufacturer coupons) currently 
being paid on behalf of participants and the type and use of payments that could be available in the future. 
LR2363(02) - Fiscal Note - Page 1 of 1