Title 18, Insurance Code

§ 3357A. Examination of affairs, transactions, accounts, and records. (a) Whenever the Commissioner considers it advisable, the Commissioner may examine the affairs, transactions, accounts, and records of a registered pharmacy benefits manager. (b) The examination must be conduct…

§ 3358. Dental services for children with a severe disability. (a) Definitions. — As used in this section: (1) “Child with a severe disability” means a person under the age of 21 who, due to a significant mental or physical condition, illness, or disease, is likely to require spe…

§ 3358A. Permit required for nonresident pharmacy to deliver prescription drugs or devices. A pharmacy benefits manager may not ship, mail, or deliver prescription drugs or devices to a person in this State through a nonresident pharmacy unless the nonresident pharmacy holds a pe…

§ 3359. Health insurance; pharmacies; electronic reimbursement. (a) This section shall apply to: (1) Insurers and nonprofit health service plans that provide, directly or through a pharmacy benefit manager, coverage for prescription drugs under health insurance policies or contra…

§ 3359A. Penalties and enforcement [Transferred]. 82 Del. Laws, c. 115, § 4Transferred to § 3373A of this title by 83 Del. Laws, c. 256, § 14, effective Oct. 26, 2021.

§ 3359B. Electronic medical (non-pharmaceutical) claims. (a) This section shall apply to all claims for healthcare services that are submitted and are not covered by § 3359 of this title. (b) For purposes of this section: (1) “Carrier” means any entity that provides health insura…

§ 3360. Screening of infants and toddlers for developmental delays. (a) Definitions. — As used in this section: (1) “Carrier” means any entity that provides health insurance in this State. For the purposes of this section, “carrier” includes an insurance company, health service c…

§ 3361. Limitations on preexisting condition limitations for minor children [Repealed].78 Del. Laws, c. 141, § 1; 80 Del. Laws, c. 310, § 1; repealed by 82 Del. Laws, c. 186, § 1, effective Aug. 6, 2019.;

§ 3361A. Definitions [For application of this section, see 83 Del. Laws, c. 256, § 15]. For purposes of this subchapter: (1) “Claim” means as defined under § 3321A of this title. (2) “Insured” means an individual covered by health insurance offered by an insurer. (3) “Insurer” me…

§ 3362. Reimbursement for orthotic and prosthetic services. (a) Definitions. — For purposes of this section: (1) “Federal reimbursement rates” means the current listed fee schedule from the Centers for Medicare and Medicaid Services, listing the current Healthcare Common Procedur…

§ 3362A. Pharmacy benefits manager network [For application of this section, see 83 Del. Laws, c. 256, § 15]. (a) A pharmacy benefits manager shall provide a reasonably adequate and accessible pharmacy benefits manager network for the provision of prescription drugs, which provid…

§ 3363. Recommended immunizations and preventive services. (a) This section applies to any health carrier providing coverage under an individual or group health benefit plan. (1) This section does not apply to grandfathered plan coverage. (2) For purposes of this section, “grandf…

§ 3363A. Reports [For application of this section, see 83 Del. Laws, c. 256, § 15; 85 Del. Laws, c. 481, § 7]. (a) A pharmacy benefits manager shall provide a pharmacy benefits manager network adequacy report describing the pharmacy benefits manager network and the pharmacy benef…

§ 3364. Specialty tier prescription coverage. (a) Unless otherwise specifically provided, the definitions herein apply throughout this section. (1) “Class of drugs” means a group of medications having similar actions designed to treat a particular disease process. (2) “Coinsuranc…

§ 3365. School-based health centers. (a) For purposes of this section, a school-based health center (SBHC) is a health clinic that: (1) Is located in or near a school facility; (2) Is organized through school and health provider relationships; (3) Except as provided by subsection…

§ 3366. Autism spectrum disorders coverage. (a) All individual health benefit plans as defined in § 3343(a) of this title shall provide coverage for the screening and diagnosis of autism spectrum disorders and the treatment of autism spectrum disorders in individuals less than 21…

§ 3367. Payment for emergency medical services. (a) As used in this section: (1) “Ambulance” shall have the same definition set forth in § 9702 of Title 16. (2) “Basic life support” shall have the same definition set forth in § 9702 of Title 16. (3) “Emergency medical services pr…

§ 3368. No lifetime or annual limits [For application of this section, see 79 Del. Laws, c. 99, § 19]. (a) (1) Except as provided in subsection (b) of this section, a health insurance issuer offering group or individual health insurance coverage may not establish any lifetime lim…

§ 3369. Notification and reasons for cancellation or nonrenewal [For application of this section, see 79 Del. Laws, c. 390, § 8]. A notice of cancellation or nonrenewal of health insurance coverage by an insurer due to nonpayment of premiums shall be in writing, shall be delivere…

§ 3370. Telehealth and telemedicine. (a) For purposes of this section: (1) “Distant site” means a site at which a health-care provider legally allowed to practice in Delaware is located while providing health-care services by means of telemedicine or telehealth. (2) “Originating …

§ 3370A. Network disclosure and transparency. (a) This section applies to every policy or contract of health insurance which is delivered or issued for delivery in this State, including each policy or contract issued by a health-service corporation, which provides medical, major …

§ 3370B. Coverage for treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections and pediatric acute onset neuropsychiatric syndrome. (a) All individual health insurance policies, contracts, or certificates that are delivered, issued for…

§ 3370C. Time of submitting claim for reimbursement. (a) For purposes of this section: (1) “Carrier” means any entity that provides health insurance in this State. “Carrier” includes an insurance company, health service corporation, health maintenance organization, and any other …

§ 3370D. Coverage for epinephrine autoinjectors. (a) For purposes of this section, “epinephrine autoinjector” means a single-use device used for the automatic injection of a premeasured dose of epinephrine into the human body. (b) All individual health insurance policies, contrac…

§ 3370E. Annual behavioral health well check. (a) As used in this section: (1) “Behavioral health well check” means a predeductible annual visit with a licensed mental health clinician with at minimum a masters level degree. The well check must include but is not limited to a rev…

§ 3370F. Supplemental and diagnostic breast examinations [For application of this section, see 84 Del. Laws, c. 121, § 5]. (a) As used in this section: (1) “Breast magnetic resonance imaging” or “breast MRI” means a diagnostic tool, including standard and abbreviated breast MRI, …

§ 3370G. Coverage for allergenic protein dietary supplements [For application of this section, see 84 Del. Laws, c. 376, § 5]. (a) For purposes of this section: (1) “Dietary supplement” means as defined in the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 321. (2) “Early egg …

§ 3370H. Services related to termination of pregnancy. (a) As used in this section: (1) “Carrier” means any entity that provides health insurance in this State that is subject to the provisions of this chapter. “Carrier” includes an insurance company, health service corporation, …

§ 3370I. Coverage for doula services. (a) “Doula services” means services provided by a trained doula and designed to provide physical, emotional, and educational support to pregnant and birthing persons, before, during, and after childbirth. “Doula services” include the followin…

§ 3370J. Pharmacist services reimbursement [For application of this section, see 85 Del. Laws, c. 253, § 23]. (a) For purposes of this section, “carrier” means any entity that provides health insurance in this State. “Carrier” includes any insurance company, managed care organiza…

§ 3370K. Annual mammograms. (a) As used in this section, “Carrier” means any entity that provides health insurance in this State that is subject to the provisions of this chapter. “Carrier” includes an insurance company, health service corporation, health maintenance organization…

§ 3370L. Developmentally-delayed speech coverage [For application of this section, see 84 Del. Laws, c. 520, § 3]. (a) For the purpose of this section “child” means a child from birth to age 18. (b) Every individual health insurance contract, including each policy or contract del…

§ 3370M. Coverage for removal of excess skin and subcutaneous tissue [For application of this section, see 85 Del. Laws, c. 88, § 5]. (a) For purposes of this section: (1) “Medically necessary” means as defined in § 3371 of this title. (2) “Panniculectomy” means an operative proc…

§ 3370N. Coverage for pre-exposure prophylaxis treatment and post-exposure prophylaxis treatment [For application of this section, see 85 Del. Laws, c. 452, § 5]. (a) As used in this section: (1) “Cost-sharing requirement” includes a deductible, coinsurance, copayment, and out-of…

§ 3370O. Coverage for diagnostic services and treatment for menopause and perimenopause [For application of this section, see 85 Del. Laws, c. 482, § 5]. (a) As used in this section: (1) “Hormone replacement therapy” means medical treatment, approved by the United States Food and…

§ 3370P. Biomarker testing [For application of this section, see 85 Del. Laws, c. 484, § 5]. (a) For purposes of this section: (1) “Biomarker” means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, o…

§ 3371. Definitions [For application of this section, see 82 Del. Laws, c. 44, § 3; 85 Del. Laws, c. 176, § 4]. For purposes of this subchapter: (1) “Adverse determination” means a benefit denial, reduction, or termination, or determination that an admission or continued stay, or…

§ 3371A. Definitions [For application of this section, see 83 Del. Laws, c. 256, § 15]. For purposes of this subchapter: (1) “Board of Pharmacy” means the Delaware Board of Pharmacy. (2) “Claim” means as defined under § 3321A of this title. (3) “Insurer” means as defined under § …

§ 3372. Disclosure and review of pre-authorization requirements; adverse determinations [For application of this section, see 85 Del. Laws, c. 176, § 4]. (a) A utilization review entity shall make any current pre-authorization requirements and restrictions readily accessible on i…

§ 3372A. Prohibited practices [For application of this section, see 83 Del. Laws, c. 256, § 15]. A pharmacy benefits manager or representative of a pharmacy benefits manager may not do any of the following: (1) Engage in spread pricing. (2) Cause or knowingly permit the use of an…

§ 3373. Utilization review entity’s obligation with respect to pre-authorization [For application of this section, see 85 Del. Laws, c. 176, § 4]. (a) If a utilization review entity requires pre-authorization of a pharmaceutical, the utilization review entity must complete its pr…

§ 3373A. Penalties and enforcement [For application of this section, see 83 Del. Laws, c. 256, § 15]. (a) If the Commissioner determines that a pharmacy benefits manager has violated any provision of this chapter or any regulation adopted under this chapter, the Commissioner may,…

§ 3374. Utilization review entity’s obligations with respect to pre-authorization concerning emergency health-care services. A utilization review entity must follow all emergency procedures and mandates as delineated in §§ 3349 and 3565 of this title.80 Del. Laws, c. 310, § 1;

§ 3374A. Prohibition of discrimination against 340B entities by pharmacy benefits managers. (a) For purposes of this section: (1) “340B drug” means a drug that is a covered outpatient drug under 42 U.S.C. § 256b. (2) “340B drug program” means the federal drug pricing program unde…

§ 3375. Retrospective denial. The utilization review entity may not revoke, limit, condition or restrict a pre-authorization on ground of medical necessity after the date the health-care provider received the pre-authorization. Any language attempting to disclaim payment for serv…

§ 3376. Effect and length of pre-authorization; limitation per episode of care [For application of this section, see 85 Del. Laws, c. 176, § 4]. (a) A pre-authorization for pharmaceuticals shall be valid for 1 year from the date the health-care provider receives the pre-authoriza…