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2022 Kentucky Revised Statutes
Chapter 304 - Insurance code
Subtitle 304.17A - Health Benefit Plans
304.17A-164 Limitations on insurers and pharmacy benefit managers regarding cost-sharing for prescription drugs -- Exceptions.

Universal Citation: KY Rev Stat § 304.17A-164 (2022)
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304.17A-164 Limitations on insurers and pharmacy benefit managers regarding cost-sharing for prescription drugs -- Exceptions. (1) (2) As used in this section: (a) "Cost sharing" means the cost to an individual insured under a health plan according to any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirements imposed by the plan, which may be subject to annual limitations on cost sharing, including those imposed under 42 U.S.C. secs. 18022(c) and 300gg-6(b), in order for an individual to receive a specific health care service covered by the plan; (b) "Generic alternative" means a drug that is designated to be therapeutically equivalent by the United States Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence Evaluations, except that a drug shall not be considered a generic alternative until the drug is nationally available; (c) "Health plan": 1. Means a policy, contract, certificate, or agreement offered or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the cost of health care services; and 2. Includes a health benefit plan as defined in KRS 304.17A-005; (d) "Insured" means any individual who is enrolled in a health plan and on whose behalf the insurer is obligated to pay for or provide health care services; (e) "Insurer" includes: 1. An insurer offering a health plan providing coverage for pharmacy benefits; or 2. Any other administrator of pharmacy benefits under a health plan; (f) "Person" means a natural person, corporation, mutual company, unincorporated association, partnership, joint venture, limited liability company, trust, estate, foundation, nonprofit corporation, unincorporated organization, government, or governmental subdivision or agency; (g) "Pharmacy" includes: 1. A pharmacy, as defined in KRS Chapter 315; 2. A pharmacist, as defined in KRS Chapter 315; or 3. Any employee of a pharmacy or pharmacist; and (h) "Pharmacy benefit manager" has the same meaning as in KRS 304.17A-161. To the extent permitted under federal law, an insurer issuing or renewing a health plan on or after January 1, 2022, or a pharmacy benefit manager, shall not: (a) Require an insured purchasing a prescription drug to pay a cost-sharing amount greater than the amount the insured would pay for the drug if he or she were to purchase the drug without coverage; (b) Exclude any cost-sharing amounts paid by an insured or on behalf of an insured by another person for a prescription drug, including any amount paid (3) (4) under paragraph (a) of this subsection, when calculating an insured's contribution to any applicable cost-sharing requirement. The requirements of this paragraph shall not apply in the case of a prescription drug for which there is a generic alternative, unless the insured has obtained access to the brand prescription drug through prior authorization, a step therapy protocol, or the insurer's exceptions and appeals process; (c) Prohibit a pharmacy from discussing any information under subsection (3) of this section; or (d) Impose a penalty on a pharmacy for complying with this section. A pharmacist shall have the right to provide an insured information regarding the applicable limitations on his or her cost-sharing pursuant to this section for a prescription drug. Subsection (2)(b) of this section shall not apply to any fully insured health benefit plan or self-insured plan provided to an employee under KRS 18A.225. Effective: January 1, 2022 History: Amended 2021 Ky. Acts ch. 134, sec. 1, effective January 1, 2022. -- Created 2018 Ky. Acts ch. 144, sec. 1, effective January 1, 2019.
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