Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 92 - MULTIPLE EMPLOYER TRUSTS AND SELF-INSURED PLANS (§§ 23-92-101 — 23-92-704) › Subchapter 5 - ARKANSAS PHARMACY BENEFITS MANAGER LICENSURE ACT (§§ 23-92-501 — 23-92-511) › Section 23-92-511 - Fairness in cost sharing - Definitions

(a)
As used in this section:
(1)
"Cost-sharing requirement" means a copayment, coinsurance, deductible, or annual limitation on cost sharing, including without limitation a limitation subject to the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, that is required by or on behalf of an enrollee in order to receive a specific healthcare service, including a prescription drug, covered by a health benefit plan;
(2)
"Enrollee" means an individual entitled to healthcare services from a healthcare insurer;
(3)
(A)
"Health benefit plan" means any individual, blanket, or group plan, policy, or contract for healthcare services issued or delivered by a healthcare insurer in this state.
(B)
"Health benefit plan" does not include:
(i)
Accident-only plans;
(ii)
Specified disease plans;
(iii)
Disability income plans;
(iv)
Plans that provide only for indemnity for hospital confinement;
(v)
Long-term-care-only plans that do not include pharmacy benefits;
(vi)
Other limited-benefit health insurance policies or plans;
(vii)
Health benefit plans provided under Arkansas Constitution, Article 5, § 32, the Workers' Compensation Law, §
11-9-101
et seq., and the Public Employee Workers' Compensation Act, §
21-5-601
et seq.;
(viii)
A plan that provides only dental benefits or eye and vision care benefits; or
(ix)
A program or plan authorized and funded under
42 U.S.C. § 1396a
et seq.;
(4)
(A)
"Healthcare insurer" means an insurance company that is subject to state law regulating insurance and offers health insurance coverage under
42 U.S.C. § 300gg-91
, as it existed on January 1, 2021, a health maintenance organization, or a hospital and medical service corporation.
(B)
"Healthcare insurer" does not include an entity that provides only dental benefits or eye and vision care benefits;
(5)
"Healthcare service" means an item or service provided to an individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability; and
(6)
"Person" means a natural person, corporation, mutual company, unincorporated association, partnership, joint venture, limited liability company, trust, estate, foundation, not-for-profit corporation, unincorporated organization, government, or governmental subdivision or agency.
(b)
(1)
When calculating an enrollee's contribution to any applicable cost-sharing requirement, a healthcare insurer shall include any cost-sharing amounts paid by the enrollee or on behalf of the enrollee by another person.
(2)
The cost-sharing requirement under subdivision (b)(1) of this section does not apply for cost-sharing of a prescription drug if a name-brand prescription drug is prescribed and the prescribed drug:
(A)
Is not considered to be medically necessary by the prescriber; and
(B)
Has a medically appropriate generic prescription drug equivalent.
(c)
(1)
Except as provided in subdivision (c)(2) of this section, this section applies to a health benefit plan that is entered into, amended, extended, or renewed on or after January 1, 2022.
(2)
(A)
Benefits offered through a health benefit plan under the Evidence-Based Prescription Drug Program of the College of Pharmacy of the University of Arkansas for Medical Sciences shall satisfy the requirements of this section beginning on and after January 1, 2024, if the Insurance Commissioner reports a failure to comply with this section to the Legislative Council.
(B)
(i)
Beginning on January 1, 2022, the Director of the Evidence-Based Prescription Drug Program of the College of Pharmacy of the University of Arkansas for Medical Sciences shall report quarterly to the commissioner, Arkansas Legislative Audit, and the Legislative Council concerning details of plan savings and how the process that is used benefits an enrollee and the offered plan.
(ii)
The report described in subdivision (c)(2)(B)(i) of this section shall include the amount of enrollee savings, plan-specific data on the amount of manufacturer rebates received, and how the manufacturer rebates were applied in each plan for which the program is contracted to administer a prescription drug benefit.
(d)
(1)
The commissioner shall promulgate rules necessary to carry out this section.
(2)
The rules promulgated under this section shall require a healthcare insurer and the director to submit plan-specific information related to savings and accountability to document how enrollees are realizing a cost savings under each plan.
(e)
The General Assembly intends for this section to regulate a healthcare insurer only to the extent permissible under applicable law.
Added by Act 2021, No. 965,§ 3, eff. 7/28/2021.