Prescription Drug Benefits Contract Term Requirements

For group benefit plan contracts between a pharmacy benefit manager (PBM) or a health insurance carrier (carrier) and an employer, certificate holder, or policyholder, the bill requires that the amount charged by the PBM or carrier to the employer, certificate holder, or policyholder for a prescription drug be equal to or less than the amount paid by the PBM or carrier to the contracted pharmacy for the drug.

The bill creates transparency requirements for PBMs and carriers regarding prescription drug benefits and grants audit authority to the department of health care policy and financing for self-funded plans and to the commissioner of insurance for fully insured plans, on request of the office of the attorney general, to ensure compliance with the requirements.

A violation of the requirements of the bill is a deceptive trade practice under the "Colorado Consumer Protection Act", with regard to self-funded plans, and a deceptive trade practice in the business of insurance, with regard to fully insured plans.

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