(1) For health benefit plans issued or renewed on or after January 1, 2025, if sterilization services are a covered service, the health benefit plan must provide the coverage regardless of the covered person's sex or gender and without deductibles, copayments, coinsurance, annual or lifetime maximum benefit limits, or other cost sharing for or limits on the coverage for sterilization services.
(2) The provisions of this section do not apply to a high deductible health benefit plan pursuant to 26 U.S.C. sec. 223, as amended, issued or renewed in this state until an eligible insured's deductible has been met, unless allowed pursuant to federal law.
Source: L. 2023: Entire section added, (SB 23-189), ch. 69, p. 258, � 4, effective April 14.
10-16-160. Cost sharing - prescription epinephrine - limits - rules - definition. (1) As used in this section, unless the context otherwise requires, epinephrine auto-injector has the same meaning as set forth in section 12-280-142 (1)(c).
(2) For health coverage plans issued or renewed on or after January 1, 2024, if a carrier provides coverage for prescription epinephrine auto-injectors, the carrier shall cap the total amount that a covered person is required to pay for all covered prescription epinephrine auto-injectors at an amount not to exceed sixty dollars for a two-pack of epinephrine auto-injectors, regardless of the amount or type of epinephrine needed to fill the covered person's prescription.
(3) Nothing in this section prevents a carrier from reducing a covered person's cost sharing to an amount that is lower than the amount specified in subsection (2) of this section.
(4) The coverage required by this section may be offered through a high deductible plan that includes a health savings account pursuant to 26 U.S.C. sec. 223 of the federal Internal Revenue Code of 1986; except that a carrier may apply deductible amounts for the required coverage if the coverage is not considered by the United States department of the treasury to be preventive or to have an acceptable deductible amount.
(5) The commissioner may use any of the commissioner's enforcement powers to obtain a carrier's compliance with this section.
(6) The commissioner may promulgate rules as necessary to implement and administer this section and to align with federal requirements.
Source: L. 2023: Entire section added, (HB 23-1002), ch. 447, p. 2631, � 2, effective August 7.
Cross references: For the legislative declaration in HB 23-1002, see section 1 of chapter 447, Session Laws of Colorado 2023.
10-16-161. Calculation of contribution to out-of-pocket and cost-sharing requirements - exception - definition - rules. (1) (a) When calculating a covered person's overall contribution to an out-of-pocket maximum or cost-sharing requirement under the covered person's health benefit plan, a carrier or PBM shall include any amount paid by the covered person or by another person on behalf of the covered person for a prescription drug if:
(I) The prescription drug does not have a generic equivalent or, for a prescription drug that is a biological product, the prescription drug does not have a biosimilar drug, as defined in 42 U.S.C. sec. 262 (i)(2), or an interchangeable biological product, as defined in 42 U.S.C. sec. 262 (i)(3); or
(II) The prescription drug has a generic equivalent, a biosimilar drug, or an interchangeable biological product, and the covered person is using the brand-name prescription drug after:
(A) Obtaining prior authorization from the carrier or pharmacy benefit manager;
(B) Complying with a step-therapy protocol required by the carrier or pharmacy benefit manager; or
(C) Receiving approval from the carrier or pharmacy benefit manager through the carrier's or pharmacy benefit manager's exceptions, appeal, or review process.
(b) A covered person is not required to comply with the utilization management processes described in subsection (1)(a)(II) of this section, including prior authorization and step-therapy protocol requirements, when those processes are prohibited under this article 16 or other applicable state law.
(2) If application of subsection (1) of this section would make a covered person's health savings account contributions ineligible under section 223 of the federal Internal Revenue Code of 1986, 26 U.S.C. sec. 223, as amended, subsection (1) of this section applies to the deductible applicable to the covered person's health benefit plan after the covered person has satisfied the minimum deductible amount under 26 U.S.C. sec. 223; except that, with respect to items or services that are preventive care pursuant to 26 U.S.C. sec. 223 (c)(2)(C), subsection (1) of this section applies, regardless of whether the minimum deductible under 26 U.S.C. sec. 223 has been satisfied.
(3) The commissioner may adopt rules as necessary to implement this section.
(4) As used in this section, cost-sharing requirement means any copayment, coinsurance, deductible, or annual limitation on cost sharing, including a limitation subject to 42 U.S.C. sec. 18022 (c) or 42 U.S.C. sec. 300gg-6 (b), required by or on behalf of a covered person in order to receive a prescription drug covered by the covered person's health benefit plan, whether covered as a medical or pharmacy benefit.
Source: L. 2023: Entire section added, (SB 23-195), ch. 351, p. 2105, � 2, effective August 7.
Editor's note: Section 3(2) of chapter 351 (SB 23-195), Session Laws of Colorado 2023, provides that the act adding this section applies to health benefit plans issued or renewed on or after January 1, 2025.
Cross references: For the legislative declaration in SB 23-195, see section 1 of chapter 351, Session Laws of Colorado 2023.
10-16-162. Prohibition on discrimination for coverage based solely on natural medicine consumption - definitions. (1) A carrier that offers, issues, or renews a health benefit plan shall not, solely on the basis of a person's consumption of natural medicine or natural medicine product:
(a) Decline or limit coverage of a person; or
(b) Penalize a covered person or reduce or limit coverage for a person.
(2) A carrier that offers, issues, or renews a health benefit plan that provides coverage for anatomical gifts, organ transplants, or related treatments or services shall not, solely on the basis of a covered person's consumption of natural medicine or natural medicine product:
(a) Deny coverage to a covered person for an organ transplant or related treatment or services;
(b) Decline or limit coverage of a covered person solely for the purpose of avoiding the requirements of this section; or
(c) Penalize a covered person or reduce or limit coverage for a covered person for health-care services related to organ transplantation, as determined in consultation with the attending physician and the covered person or the covered person's representative.
(3) This section does not require a health benefit plan to provide coverage for the donation of an anatomical gift, an organ transplant, or related treatment or services.
(4) As used in this section, unless the context otherwise requires:
(a) Anatomical gift means the donation of part of a human body for the purpose of transplantation to another person.
(b) (I) Natural medicine means the following substances:
(A) Dimethyltryptamine;
(B) Mescaline;
(C) Ibogaine;
(D) Psilocybin; or
(E) Psilocin.
(II) Natural medicine does not mean a synthetic or synthetic analog of the substances listed in this subsection (4)(b), including a derivative of a naturally occurring compound of natural medicine that is produced using chemical synthesis, chemical modification, or chemical conversion.
(c) Natural medicine product means a product infused with natural medicine that is intended for consumption.
Source: L. 2023: Entire section added, (SB 23-290), ch. 249, p. 1418, � 32, effective July 1. L. 2024: (4)(b)(I)(E) amended, (SB 24-198), ch. 452, p. 3138, � 1, effective June 6.
10-16-163. Contracts - health benefit plans - pharmacy benefit managers - policyholders - transparency requirements - rules - definitions. (1) For a contract between a carrier or pharmacy benefit manager and a certificate holder or policyholder that is issued or renewed on or after January 1, 2025, the amount charged by the carrier or PBM to the certificate holder or policyholder for a prescription drug dispensed to a covered person must be equal to or less than the amount paid by the carrier or PBM to a contracted pharmacy for such prescription drug dispensed to such covered person residing in Colorado.
(2) (a) For group health benefit plans in effect during calendar year 2025 and each calendar year thereafter, a carrier or pharmacy benefit manager shall disclose to each policyholder or the policyholder's specifically designated broker or consultant the prescription drug contract terms required by this subsection (2). For group health benefit plans in effect during calendar year 2023 or 2024 or both, the disclosure must also include any changes in terms between each calendar year.
(b) The disclosures required pursuant to this subsection (2) must include:
(I) The ingredient cost average reimbursement rate for:
(A) Generic drugs dispensed at retail pharmacies;
(B) Brand-name drugs dispensed at retail pharmacies;
(C) Specialty drugs dispensed at retail pharmacies;
(D) Generic drugs dispensed at mail-order pharmacies;
(E) Brand-name drugs dispensed at mail-order pharmacies;
(F) Specialty drugs dispensed at mail-order pharmacies; and
(G) Specialty drugs dispensed at any specialty pharmacy, including a pharmacy that is fully or partially owned by a contracting PBM, a carrier, or the PBM's or carrier's holding companies or affiliates;
(II) The average dispensing fee paid to each type of pharmacy, including each retail, mail-order, and specialty pharmacy;
(III) The charge per prior authorization;
(IV) Utilization management programs and associated fees;
(V) Any other contracted services and associated fees;
(VI) The average rebate across all paid prescriptions for the respective group health benefit plan and the average rebate across all paid prescriptions that pay a rebate for the respective group health benefit plan; and
(VII) The rebate guarantee, where applicable.
(c) For contracts between a carrier or pharmacy benefit manager and a certificate holder or policyholder that are renewed in calendar year 2025 and each calendar year thereafter, the carrier or PBM shall calculate and communicate to the certificate holder or policyholder the value of the difference between the contract terms in the renewed contracts and the contracts that were in effect the previous calendar year, annualizing the previous year's actual data for each respective certificate holder or policyholder. The value communicated shall include annual aggregate savings, annual aggregate savings per employee per year, and annual aggregate savings per covered person per year.
(d) A carrier or pharmacy benefit manager shall provide to each certificate holder or policyholder, for voluntary consideration, options to repurpose aggregate savings in the form of reductions to out-of-pocket costs such as deductibles, copayment amounts, coinsurance, or premium contributions. The carrier or PBM shall provide the information to certificate holders or policyholders no less than ninety days before the date of the contract renewal.
(e) A carrier or PBM shall provide the information specified in subsections (2)(b), (2)(c), and (2)(d) of this section to all certificate holders and policyholders for contracts in effect during calendar year 2025, including certificate holders and policyholders that may not receive a renewal notice due to a multiyear contractual agreement or for any other reason except notice of termination.
(f) The disclosures required in subsections (2)(b)(VI) and (2)(b)(VII) of this section must not disclose any proprietary rebate information between a drug manufacturer and the pharmacy benefit manager or its carrier affiliate. The disclosure of data required by these subsections must represent the aggregate value of rebates passing through from the pharmacy benefit manager or its carrier affiliate to the health benefit plan as defined by rule of the commissioner.
(g) A carrier may exempt a segment of its business from this subsection (2). The carrier's exempted business segment must provide the majority of covered medical professional services through a single, contracted medical group and operate its own pharmacies through which at least eighty-five percent of its aggregate prescription drug claims are filled. On and after August 7, 2023, a carrier that meets the exemption criteria in this subsection (2)(g) shall submit an attestation to the division of such compliance with each rate filing required pursuant to section 10-16-107. The carrier or PBM shall disclose all data requirements as outlined in this subsection (2) to the carrier's group policyholders that are primarily accessing prescription drug benefits through a third-party PBM contracted with the carrier.
(3) The commissioner shall promulgate rules to implement this section.
(4) (a) The commissioner may conduct an audit or market conduct examination of a carrier or pharmacy benefit manager to ensure compliance with this section. The commissioner, pursuant to any rules promulgated by the division, may audit a carrier or PBM annually to determine if there is a violation of this section.
(b) The commissioner may determine a carrier's or PBM's compliance with this section based on a sampling of data or based on a full claims audit. The sampling of data and any extrapolation from the data used to determine penalties must be reasonably valid from a statistical standpoint and in accordance with generally accepted auditing standards. A carrier or PBM that does not comply with a division request for the data required to complete an audit violates this section and may be subject to penalties.
(c) Information obtained through an audit conducted pursuant to this subsection (4) is proprietary and confidential information, available only to the commissioner and the commissioner's auditing designee, and is not subject to disclosure unless specifically required by state or federal law.
(5) The failure of a carrier or PBM to comply with this section is an unfair method of competition and an unfair or a deceptive act or practice in the business of insurance pursuant to section 10-3-1104 (1).
(6) (a) The requirements of subsections (1), (2), and (4) of this section apply to an employer-sponsored health benefit plan, an associated pharmacy benefit manager, and the health benefit plan members only if a person, Taft-Hartley trust, municipality, state, labor union, plan sponsor, or employer that provides the employer-sponsored health benefit plan elects to be subject to subsections (1), (2), and (4) of this section for its members that reside in Colorado.
(b) As used in this subsection (6), pharmacy benefit manager means an entity doing business in this state that administers or manages prescription drug benefits, including claims processing services and other prescription drug or device services as defined in section 10-16-122.1, that is in a contractual relationship directly or indirectly through an affiliate with an employer-sponsored health benefit plan, which includes plans that are self-insured or regulated by the federal Employee Retirement Income Security Act of 1974, 29 U.S.C. sec. 1001 et seq., as amended, offered by:
(I) A person;
(II) A Taft-Hartley trust;
(III) A municipality;
(IV) The state;
(V) A labor union;
(VI) A plan sponsor;
(VII) An employer; or
(VIII) A coalition of employers or aggregation of employers working together to negotiate improved contract terms with a pharmacy benefit manager.
(7) As used in this section, unless the context otherwise requires:
(a) Contracted pharmacy means a pharmacy that has contracted with a carrier, a pharmacy benefit manager, or an affiliate of the carrier or PBM.
(b) Ingredient cost means the actual amount paid to a pharmacy by a pharmacy benefit manager for a prescription drug, not including a dispensing fee or patient cost-sharing amount.
(c) Pharmacy means an entity where medicinal drugs are dispensed and sold, including a retail pharmacy, mail-order pharmacy, specialty pharmacy, hospital outpatient setting, or other related pharmacy.
Source: L. 2023: Entire section added, (HB 23-1201), ch. 158, p. 684, � 1, effective August 7.