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Coverage Requirements For Health-care Products

Concerning coverage requirements for health-care products, and, in connection therewith, making an appropriation.
2022 Regular Session
Health Care & Health Insurance
Bill Summary

Beginning in 2023, the bill requires each health insurance carrier (carrier) that offers an individual or small group health benefit plan in this state to offer at least 25% of its health benefit plans on the Colorado health benefit exchange (exchange) and at least 25% of its plans not on the exchange in each bronze, silver, gold, and platinum benefit level in each service area as copayment-only payment structures for all prescription drug cost tiers.

Starting in 2024, a carrier or, if a carrier uses a pharmacy benefit manager (PBM) for claims processing services or other prescription drug or device services under a health benefit plan offered by the carrier, the PBM, or a representative of the carrier or the PBM, is prohibited from modifying or applying a modification to the current prescription drug formulary during the current plan year.

The bill repeals and reenacts the current requirements for step therapy and requires a carrier to use clinical review criteria to establish the step-therapy protocol.

For each health benefit plan issued or renewed on or after January 1, 2024, the bill requires each carrier or PBM to demonstrate to the division of insurance that:

  • 100% of the estimated rebates received or to be received in connection with dispensing or administering prescription drugs included in the carrier's prescription drug formulary are used to reduce costs for the employer or individual purchasing the plan;
  • For small group and large employer health benefit plans, all rebates are used to reduce employer and individual employee costs; and
  • For individual health benefit plans, all rebates are used to reduce consumers' premiums and out-of-pocket costs for prescription drugs to the extent practicable.

The bill requires the commissioner of insurance (commissioner) to promulgate rules to implement prescription drug pass-through requirements for carriers. Each carrier or PBM is required to report annually specified prescription drug rebate information to the commissioner.

Beginning in 2023, the bill requires the department of health care policy and financing, in collaboration with the administrator of the all-payer claims database, to conduct an annual analysis of the prescription drug rebates received in the previous calendar year, by carrier and prescription drug tier, and make the analysis available to the public.

(Note: This summary applies to this bill as introduced.)


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