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7 LONG TITLE
8 General Description:
9 This bill enacts provisions relating to cost sharing for certain prescription drugs.
10 Highlighted Provisions:
11 This bill:
12 ▸ prohibits a health benefit plan from excluding payments made on behalf of an
13 insured when determining whether the insured has satisfied the plan's cost sharing
14 requirements.
15 Money Appropriated in this Bill:
16 None
17 Other Special Clauses:
18 None
19 Utah Code Sections Affected:
20 ENACTS:
21 31A-22-657, Utah Code Annotated 1953
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23 Be it enacted by the Legislature of the state of Utah:
24 Section 1. Section 31A-22-657 is enacted to read:
25 31A-22-657. Application of certain payments made on behalf of an insured to cost
26 sharing requirements.
27 (1) As used in this section:
28 (a) (i) "Cost sharing requirement" means copayments, coinsurance, deductibles, and
29 other requirements for payment an insured is required to make under the provisions of a health
30 benefit plan.
31 (ii) "Cost sharing requirement" does not include premiums.
32 (b) "Generic equivalent" means a drug product that is designated in the Approved Drug
33 Products with Therapeutic Equivalence Evaluations prepared by the Center for Drug
34 Evaluation and Research of the United States Food and Drug Administration as:
35 (i) the therapeutic equivalent of another drug product; and
36 (ii) an "A" rated drug product.
37 (c) "Manufacturer" means the same as that term is defined in Section 31A-48-102.
38 (d) "Qualified prescription drug" means a prescription drug, as defined in Section
39 58-17b-102, that is covered by the insurer under the insured's health benefit plan and for which:
40 (i) there is no generic equivalent or interchangeable biological product, as defined in
41 Section 58-17b-605.5;
42 (ii) there is no covered drug in the same therapeutic class used to treat the insured's
43 condition that is preferred under a formulary for the insured's health benefit plan; or
44 (iii) if applicable to the prescription drug under the insured's health benefit plan, the
45 insured has:
46 (A) received preauthorization from the health benefit plan for the prescription drug in
47 accordance with Section 31A-22-650;
48 (B) completed the health benefit plan's step therapy protocol or other utilization
49 management requirement for the prescription drug; or
50 (C) received authorization for the prescription drug as the result of an internal or
51 independent review in accordance with Section 31A-22-629.
52 (2) For a plan entered into or renewed on or after January 1, 2023, when determining
53 whether an insured has satisfied a health benefit plan's cost sharing requirement, the health
54 benefit plan may not exclude payments made on behalf of the insured for a qualified
55 prescription drug.
56 (3) Notwithstanding Subsection (2), if application of Subsection (2) would result in
57 health savings account ineligibility under 26 U.S.C. Sec. 223, payments made on behalf of an
58 insured for a qualified prescription drug that is not preventive care under 26 U.S.C. Sec.
59 223(c)(2)(C) shall apply to the insured's health savings account-qualified high deductible health
60 plan cost sharing requirement only after the insured has satisfied the health benefit plan's
61 deductible.