2022 Colorado Code
Title 10 - Insurance
Article 16 - Health-Care Coverage
Part 1 - General Provisions
§ 10-16-122.1. Contracts Between Pbms and Pharmacies - Carrier Submit List of Pbms - Prohibited Practices - Exception - Short Title - Definitions

1. The short title of this section is the "Pharmacy Fairness Act".
2. 1. Starting in 2022, each carrier shall submit to the commissioner, contemporaneously with its rate filing pursuant to section 10-16-107 and in a form and manner specified by the commissioner by rule, a list of all pharmacy benefit managers the carrier contracts with or otherwise uses for claims processing services or other prescription drug or device services under health coverage plans the carrier offers.
   2. The list of PBMs submitted to the commissioner pursuant to this subsection (2) is considered proprietary and confidential information and is not subject to disclosure under the "Colorado Open Records Act", part 2 of article 72 of title 24.

3. Starting in 2022, a PBM or the representative of a PBM shall not:
   1. 1. With regard to individual and group health benefit plans, preclude covered persons from accessing prescription drug benefits under the health benefit plan at an in-network retail pharmacy unless:
         1. The FDA has restricted distribution of the prescription drug; or
         2. The prescription drug requires special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy.

      2. A health benefit plan may impose a different cost-sharing amount for obtaining a covered prescription drug at a retail pharmacy, but all cost sharing must count towards the plan's annual limitation on cost sharing specified in 45 CFR 156.130 and must be accounted for in the plan's actuarial value calculated under 45 CFR 156.135.

   2. Charge a pharmacy or pharmacist a fee related to the adjudication of a pharmacist services claim, other than a one-time, reasonable fee, not to exceed the lesser of twenty-five percent of the pharmacy dispensing fee or twenty-five cents, for receipt and processing of the same pharmacist services claim; or
   3. Require pharmacy accreditation standards or certification requirements inconsistent with, more stringent than, or in addition to requirements applicable to similarly situated PBM-affiliated pharmacies within the same PBM network.

4. This section does not apply to the administration or management of the drug assistance program authorized pursuant to section 25-4-1401.
5. As used in this section and section 10-16-122.9, unless the context otherwise requires:
   1. "Claims processing services" means the administrative services performed in connection with processing and adjudicating claims related to pharmacist services, which services include:
      1. Receiving payments for pharmacist services; or
      2. Making payments to pharmacies or pharmacists for pharmacist services.

   2. "Other prescription drug or device services" means services, other than claims processing services, provided directly or indirectly and either in connection with or separate from claims processing services. The term includes:
      1. Managing or participating in incentive programs or arrangements for pharmacist services;
      2. Negotiating or entering into contractual arrangements with pharmacies or pharmacists;
      3. Developing formularies;
      4. Designing prescription drug benefits programs; and
      5. Advertising or promoting services.

   3. "PBM-affiliated pharmacy" means a pharmacy or pharmacist that, either directly or indirectly through one or more intermediaries, owns or controls or is owned or controlled by a PBM.
   4. "PBM network" means a network of pharmacies or pharmacists that are offered an agreement or contract to provide pharmacist services for a health benefit plan.
   5. "Pharmacist" has the same meaning as set forth in section 12-280-103 (35).
   6. "Pharmacist services" means products, goods, and services provided as a part of the practice of pharmacy, as defined in section 12-280-103 (39).
   7. "Pharmacy" has the same meaning as set forth in section 12-280-103 (43).

Source: L. 2021: Entire section added, (HB 21-1297), ch. 452, p. 2992, § 3, effective July 6.

Cross references: For the legislative declaration in HB 21-1297, see section 1 of chapter 452, Session Laws of Colorado 2021.