(1) As used in this section, unless the context otherwise requires:
(a) Carrier means a carrier offering a health benefit plan.
(b) Contraception has the same meaning as contraceptive or contraception set forth in section 2-4-401 (1.5).
(c) Dispensing entity means a pharmacy, other outlet, or other facility registered by the state board of pharmacy under part 1 of article 280 of title 12 that dispenses or furnishes contraception.
(2) As part of the coverage required for contraception pursuant to section 10-16-104 (3)(a)(I), (18), or (18.1), as applicable, a carrier or a pharmacy benefit management firm acting on behalf of the carrier shall provide coverage for, and shall reimburse a provider or an in-network dispensing entity for, the single dispensing or furnishing of contraception intended to last the covered person for a duration of twelve months, as permitted by the covered person's prescription, dispensed or furnished at one time, unless requested otherwise by the covered person.
(3) A carrier or pharmacy benefit management firm acting on behalf of the carrier shall:
(a) Allow for the continuous use of clinically appropriate contraception as determined by the prescribing provider;
(b) Reimburse a provider or an in-network dispensing entity per unit for dispensing or furnishing contraception;
(c) Not implement step therapy, prior authorization, or other utilization management practices, including quantity or fill limits, for contraception coverage if the practice would result in a covered person receiving less than a twelve-months' duration of contraception dispensed or furnished either at one time or, if requested by the covered person at the point of dispensing or furnishing, over a twelve-month period;
(d) Include an alternative prescribed contraception without prior authorization, step therapy, or cost sharing if, in the determination and judgment of the prescribing provider, the alternative prescribed contraception is medically necessary;
(e) Make available an easily accessible, timely, and transparent exceptions process for a covered person to obtain coverage, without cost sharing, for medically necessary contraception that is not otherwise included in the formulary or available without cost sharing;
(f) Not require a prescription for coverage of FDA-approved, -cleared, or -granted over-the-counter contraception; and
(g) Include point-of-sale coverage for over-the-counter contraception at in-network dispensing entities without prior authorization, step therapy, utilization management, or cost sharing.
(4) (a) Carriers shall report annually to the commissioner regarding the coverage of contraception required pursuant to section 10-16-104 (3)(a)(I), (18), or (18.1). At a minimum, the reporting requirements must include annual reporting of data relating to contraception coverage provided in the previous calendar year.
(b) For purposes of the carrier's required reporting to the commissioner pursuant to subsection (4)(a) of this section, a pharmacy benefit management firm acting on behalf of a carrier shall annually provide data to the carrier relating to contraception coverage in the previous calendar year, and the carrier shall include the data provided by a pharmacy benefit management firm in its annual report required by subsection (4)(a) of this section.
(5) The commissioner may promulgate rules to implement this section.
Source: L. 2017: Entire section added, (HB 17-1186), ch. 324, p. 1745, � 1, effective January 1, 2019. L. 2019: (2)(a) amended, (HB 19-1172), ch. 136, p. 1654, � 42, effective October 1. L. 2023: Entire section R&RE, (SB 23-284), ch. 276, p. 1629, � 1, effective August 7.
10-16-104.3. Health coverage for persons under twenty-six years of age - coverage for students who take medical leave of absence. (1) (a) A carrier that offers a health benefit plan in the state and that makes dependent coverage for children available under the health benefit plan shall make the coverage available for a child who is under twenty-six years of age. The carrier shall not deny or restrict coverage for a child who is under twenty-six years of age based on a factor such as:
(I) Residency with the policyholder or any other person;
(II) The presence or absence of financial dependence on the policyholder or any other person;
(III) Marital or civil union status;
(IV) Student status;
(V) Employment status; or
(VI) A combination of any of the factors listed in paragraphs (a) to (d) of this subsection (1).
(b) A carrier shall not deny dependent coverage of a child based on the child's eligibility for other coverage.
(c) Except as otherwise provided in state law, a carrier offering dependent coverage of children in a health benefit plan shall not vary the terms of coverage in the policy or contract based on age, except for premium rates for children who are twenty-one years of age or older.
(d) Nothing in this subsection (1) requires a carrier to make coverage available for the child of a child receiving dependent coverage unless the grandparent becomes the permanent legal guardian or adoptive parent of that grandchild.
(2) Repealed.
(3) (a) All individual and group sickness and accident insurance policies providing coverage within the state by an entity subject to the provisions of part 2 of this article and all group health service contracts issued by an entity subject to the provisions of part 3 or 4 of this article that provide dependent coverage to a child who is enrolled in a postsecondary educational institution shall not terminate coverage due to a medically necessary leave of absence before the date that is the earlier of:
(I) One year after the first day of the medically necessary leave of absence; or
(II) The date the coverage would otherwise terminate under the terms of the plan or health insurance coverage.
(b) For purposes of this subsection (3), medically necessary leave of absence means a leave of absence from a postsecondary educational institution or a change in enrollment of the dependent at the institution that:
(I) Begins while the dependent is suffering from a serious illness;
(II) Is medically necessary; and
(III) Causes the dependent to lose student status for the purpose of dependent coverage.
Source: L. 2005: Entire section added, p. 1503, � 1, effective January 1, 2006. L. 2009: (3) added, (HB 09-1338), ch. 353, p. 1844, � 5, effective July 1. L. 2013: (1) R&RE and (2) repealed, (HB 13-1266), ch. 217, p. 925, � 4, effective May 13.
10-16-104.4. Child-only plans - legislative declaration - open enrollment - reporting requirements - repeal. (Repealed)
Source: L. 2011: Entire section added, (SB 11-128), ch. 133, p. 468, � 3, effective April 29. L. 2013: (2)(b) amended, (HB 13-1266), ch. 217, p. 926, � 5, effective May 13.
Editor's note: Subsection (6) provided for the repeal of this section, effective January 1, 2014. (See L. 2011, p. 468.)