Health plans may impose cost-sharing as part of the prescription drug benefit of a health plan. This cost-sharing can vary depending on the health plan and the type of drug. Generally, enrollee cost-sharing for prescription drugs counts against the enrollee's out-of-pocket maximum, which is the enrollee's maximum financial responsibility for the plan year. However, federal law permits health carriers to restrict whether third-party payments count toward the out-of-pocket maximum.
For non-grandfathered health plans (including health plans offered to state and school employees) issued or renewed on or after January 1, 2023, a health carrier or a health care benefit manager must include cost-sharing amounts paid on behalf of the enrollee for certain prescription drugs when calculating the enrollee's contribution to any applicable cost-sharing or out-of-pocket maximum. The amounts must be applied toward the enrollee's applicable cost-sharing or out-of-pocket maximum in full at the time it is rendered.
This requirement is applicable to drugs that either do not have a generic equivalent or drugs for which the enrollee obtained access via prior authorization, step therapy, or an exception process. The requirement does not apply, however, to drugs not subject to a deductible.
The requirement does not apply to a qualifying health plan for a health savings account to the extent necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from a health savings account under Internal Revenue Service laws, regulations, and guidance.
The Insurance Commissioner may adopt any rules necessary to implement these requirements.