C.R.S.
Section 10-16-122.9
Prescription drug benefits
- real-time access to benefit information
- enforcement
- definitions
- rules
(1)
Intentionally left blank —Ed.(a)
Upon request of a covered person, the covered person’s provider, or a third party on behalf of the covered person or provider, a carrier or, if a carrier uses a pharmacy benefit manager for claims processing services or other prescription drug or device services under a health benefit plan offered by the carrier, the PBM shall furnish the cost, benefit, and coverage data set forth in subsection (1)(c) of this section to the covered person, the covered person’s provider, or the third party acting on behalf of the covered person or provider and shall ensure that the data is:(I)
Current and updated no later than one business day after any change is made;(II)
Provided in real time; and(III)
Provided in the same format that the request is made by the covered person, provider, or third party that made the request.(b)
Intentionally left blank —Ed.(I)
A covered person, the covered person’s provider, or a third party acting on behalf of the covered person or provider shall submit the request for cost, benefit, and coverage data and the carrier or PBM shall respond to the request using established industry content and transport standards published by:(A)
A standards-developing organization accredited by the American National Standards Institute or its successor entity, including the National Council for Prescription Drug Programs, the Accredited Standards Committee, or Health Level Seven International, or their successor entities; or(B)
A relevant federal or state governing body, including the CMS or the office of the national coordinator for health information technology in the federal department of health and human services.(II)
A facsimile, proprietary payer or patient portal, or other electronic form is not an acceptable electronic format pursuant to this section.(c)
Intentionally left blank —Ed.(I)
Upon receipt of a request for cost, benefit, and coverage data pursuant to this subsection (1), the carrier or PBM, as applicable, shall provide the following data for any drug covered under the covered person’s health benefit plan:(A)
The covered person’s eligibility information for the drug;(B)
A list of any clinically appropriate alternatives to the drug that are covered under the covered person’s health benefit plan;(C)
Cost-sharing information for the drug and for clinically appropriate alternatives, including a description of any variance in cost-sharing based on a pharmacy, whether retail or mail order, or provider dispensing or administering the drug or alternatives; and(D)
Any applicable utilization management requirements for the drug or clinically appropriate alternatives, including prior authorization, step therapy, quantity limits, and site-of-service restrictions.(II)
The carrier or PBM shall furnish the data specified in subsection (1)(c)(I) of this section, whether the request is made using the drug’s unique billing code, such as a national drug code or Healthcare Common Procedure Coding System code, or a descriptive term, such as the brand or generic name of the drug. A carrier or PBM shall not deny or delay a request for cost, benefit, and coverage data as a method of blocking the data from being shared based on how the drug was requested.(d)
A carrier or PBM furnishing the data requested pursuant to this subsection (1) shall not:(I)
Restrict, prohibit, or otherwise hinder a provider from communicating or sharing with the covered person:(A)
Any of the data set forth in subsection (1)(c)(I) of this section;(B)
Additional information on any lower-cost or clinically appropriate alternatives, whether or not the alternatives are covered under the covered person’s plan; or(C)
Additional payment or cost-sharing information that may reduce the covered person’s out-of-pocket costs, such as cash price or patient assistance and support programs, whether sponsored by a manufacturer, foundation, or other entity;(II)
Except as may be required by law, interfere with, prevent, or materially discourage access, exchange, or use of the data set forth in subsection (1)(c)(I) of this section, which may include:(A)
Charging fees;(B)
Failing to respond to a request, at the time the request is made, when a response is reasonably possible;(C)
Implementing technology in nonstandard ways or instituting covered person consent requirements, processes, policies, procedures, or renewals that are likely to substantially increase the complexity or burden of accessing, exchanging, or using the data; or(III)
Penalize a provider for disclosing the information to a covered person or prescribing, administering, or ordering a clinically appropriate or lower-cost alternative.(e)
A carrier or PBM shall treat a personal representative of a covered person as the covered person for purposes of this section. If, under applicable law, a person has authority to act on behalf of a covered person in making decisions related to health care, a carrier or PBM, or affiliates or entities acting on behalf of the carrier or PBM, must treat the person as a personal representative of the covered person for purposes of this section.(1.5)
With regard to the requirements of this section applicable to PBMs, the commissioner has the authority to enforce this section and to impose a penalty or other remedy against a PBM that fails to comply with this section.(1.7)
The commissioner may adopt rules to implement and enforce this section.(2)
As used in this section, unless the context otherwise requires:(a)
“CMS” means the federal centers for medicare and medicaid services in the United States department of health and human services.(b)
“Cost-sharing information” means the amount a covered person is required to pay for a drug that is covered under the covered person’s health benefit plan.(c)
“Covered” or “coverage” means those health-care services to which a covered person is entitled under the terms of the covered person’s health benefit plan.(d)
“Drug” means any prescription drug or medication covered under a health benefit plan, whether ordered, prescribed, or administered.(e)
“Healthcare Common Procedure Coding System” means the system developed by the CMS for identifying health-care services in a consistent and standardized manner.(f)
“National drug code” means the unique, three-segment identifier number used by the FDA to identify drugs that are manufactured, prepared, propagated, compounded, or processed for sale in the United States.(g)
“Third party” means a person, other than a PBM, that is not an enrollee in or a covered person under a health benefit plan.
Source:
Section 10-16-122.9 — Prescription drug benefits - real-time access to benefit information - enforcement - definitions - rules, https://leg.colorado.gov/sites/default/files/images/olls/crs2023-title-10.pdf (accessed Oct. 20, 2023).
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