2023 Colorado Revised Statutes › Title 10 - INSURANCE (§§ 10-1-101 — 10-23-110) › HEALTH CARE COVERAGE (§§ 10-16-101 — 10-16.5-101) › Article 16 - HEALTH-CARE COVERAGE (§§ 10-16-101 — 10-16-1506) › Part 1 - GENERAL PROVISIONS (§§ 10-16-101 — 10-16-169) › Section 10-16-161 - Calculation of contribution to out-of-pocket and cost-sharing requirements - exception - definitions - rules

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Editor's note: For the applicability of this section on or after January 1, 2025, see the editor's note following this section.
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(1)
(a)
When calculating a covered person's overall contribution to an out-of-pocket maximum or cost-sharing requirement under the covered person's health benefit plan, a carrier or PBM shall include any amount paid by the covered person or by another person on behalf of the covered person for a prescription drug if:
(I)
The prescription drug does not have a generic equivalent or, for a prescription drug that is a biological product, the prescription drug does not have a biosimilar drug, as defined in
42 U.S.C. sec. 262 (i)(2)
, or an interchangeable biological product, as defined in
42 U.S.C. sec. 262 (i)(3)
; or
(II)
The prescription drug has a generic equivalent, a biosimilar drug, or an interchangeable biological product, and the covered person is using the brand-name prescription drug after:
(A)
Obtaining prior authorization from the carrier or pharmacy benefit manager;
(B)
Complying with a step-therapy protocol required by the carrier or pharmacy benefit manager; or
(C)
Receiving approval from the carrier or pharmacy benefit manager through the carrier's or pharmacy benefit manager's exceptions, appeal, or review process.
(b)
A covered person is not required to comply with the utilization management processes described in subsection (1)(a)(II) of this section, including prior authorization and step-therapy protocol requirements, when those processes are prohibited under this article 16 or other applicable state law.
(2)
If application of subsection (1) of this section would make a covered person's health savings account contributions ineligible under section 223 of the federal "Internal Revenue Code of 1986",
26 U.S.C. sec. 223
, as amended, subsection (1) of this section applies to the deductible applicable to the covered person's health benefit plan after the covered person has satisfied the minimum deductible amount under
26 U.S.C. sec. 223
; except that, with respect to items or services that are preventive care pursuant to
26 U.S.C. sec. 223 (c)(2)(C)
, subsection (1) of this section applies, regardless of whether the minimum deductible under
26 U.S.C. sec. 223
has been satisfied.
(3)
The commissioner may adopt rules as necessary to implement this section.
(4)
As used in this section, "cost-sharing requirement" means any copayment, coinsurance, deductible, or annual limitation on cost sharing, including a limitation subject to
42 U.S.C. sec. 18022 (c)
or
42 U.S.C. sec. 300gg
-
6 (b)
, required by or on behalf of a covered person in order to receive a prescription drug covered by the covered person's health benefit plan, whether covered as a medical or pharmacy benefit.
Added by 2023 Ch. 351,§ 2, eff. 8/7/2023, app. to health benefit plans issued or renewed on or after 1/1/2025.
2023 Ch. 351, was passed without a safety clause. See Colo. Const. art. V, § 1(3).