HB1604: Cost sharing; out-of-pocket expense credit.

Legislative Summary

Cost sharing; out-of-pocket expense credit. Requires an insurer, an administrator, and a pharmacy benefit manager to apply the annual limitation on cost sharing set forth in the federal Patient Protection and Affordable Care Act under 42 U.S.C. 18022(c)(1) to prescription drugs that: (1) are covered under a health plan; (2) are life-saving or intended to manage chronic pain; and (3) do not have an approved generic version. Provides that an insurer, an administrator, and a pharmacy benefit manager may not directly or indirectly set, alter, implement, or condition the terms of health insurance coverage based in part or entirely on information about the availability or amount of financial or product assistance available for a prescription drug. Requires, before December 31 of each year, each insurer and administrator to certify to the insurance commissioner that the insurer or administrator has fully and completely complied with the cost sharing requirements during the previous calendar year. Requires a health plan to credit toward a covered individual's deductible and annual maximum out-of-pocket expenses any amount the covered individual pays directly to any health care provider for a medically necessary covered health care service if a claim for the health care service is not submitted to the health plan and the amount paid by the covered individual to the health care provider is less than the average discounted rate for the health care service paid to a health care provider in the health plan's network. Requires a health plan to: (1) establish a procedure by which a covered individual may claim a credit; and (2) identify documentation necessary to support a claim for a credit.