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General Assembly Substitute Bill No. 5386
February Session, 2022
AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR
EPINEPHRINE CARTRIDGE INJECTORS, HEALTH CARRIERS AND
PHARMACY BENEFIT MANAGERS .
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. (NEW) (Effective January 1, 2023) (a) Each individual health 1
insurance policy providing coverage of the type specified in 2
subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 of the 3
general statutes delivered, issued for delivery, renewed, amended or 4
continued in this state on or after January 1, 2023, that includes coverage 5
for outpatient prescription drugs shall provide coverage for at least one 6
epinephrine cartridge injector, as defined in section 19a-909 of the 7
general statutes. 8
(b) No policy described in subsection (a) of this section shall impose 9
a coinsurance, copayment, deductible or other out-of-pocket expense for 10
the epinephrine cartridge injector that such policy is required to cover 11
pursuant to said subsection (a) in an amount that is greater than twenty-12
five dollars. The provisions of this subsection shall apply to a high 13
deductible health plan, as that term is used in subsection (f) of section 14
38a-493 of the general statutes, to the maximum extent permitted by 15
federal law, except if such plan is used to establish a medical savings 16
account or an Archer MSA pursuant to Section 220 of the Internal 17 Substitute Bill No. 5386
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Revenue Code of 1986, or any subsequent corresponding internal 18
revenue code of the United States, as amended from time to time, or a 19
health savings account pursuant to Section 223 of said Internal Revenue 20
Code, as amended from time to time. The provisions of this subsection 21
shall apply to such high deductible health plans to the maximum extent 22
that (1) is permitted by federal law, and (2) does not disqualify such 23
account for the deduction allowed under Section 220 or 223, of the 24
Internal Revenue Code of 1986, as applicable. 25
Sec. 2. (NEW) (Effective January 1, 2023) (a) Each group health 26
insurance policy providing coverage of the type specified in 27
subdivisions (1), (2), (4), (11), (12) and (16) of section 38a-469 of the 28
general statutes delivered, issued for delivery, renewed, amended or 29
continued in this state on or after January 1, 2023, that includes coverage 30
for outpatient prescription drugs shall provide coverage for at least one 31
epinephrine cartridge injector, as defined in section 19a-909 of the 32
general statutes. 33
(b) No policy described in subsection (a) of this section shall impose 34
a coinsurance, copayment, deductible or other out-of-pocket expense for 35
the epinephrine cartridge injector that such policy is required to cover 36
pursuant to said subsection (a) in an amount that is greater than twenty-37
five dollars. The provisions of this subsection shall apply to a high 38
deductible health plan, as that term is used in subsection (f) of section 39
38a-520 of the general statutes, to the maximum extent permitted by 40
federal law, except if such plan is used to establish a medical savings 41
account or an Archer MSA pursuant to Section 220 of the Internal 42
Revenue Code of 1986, or any subsequent corresponding internal 43
revenue code of the United States, as amended from time to time, or a 44
health savings account pursuant to Section 223 of said Internal Revenue 45
Code, as amended from time to time. The provisions of this subsection 46
shall apply to such high deductible health plans to the maximum extent 47
that (1) is permitted by federal law, and (2) does not disqualify such 48
account for the deduction allowed under Section 220 or 223, of said the 49
Internal Revenue Code of 1986, as applicable. 50 Substitute Bill No. 5386
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Sec. 3. Section 38a-479ooo of the general statutes is repealed and the 51
following is substituted in lieu thereof (Effective January 1, 2023): 52
For the purposes of this part and section 4 of this act: 53
(1) "Commissioner" means the Insurance Commissioner. 54
(2) "Department" means the Insurance Department. 55
(3) "Drug" has the same meaning as provided in section 21a-92. 56
(4) "Health care plan" means an individual or a group health 57
insurance policy that provides coverage of the types specified in 58
subdivisions (1), (2), (4), (11) and (12) of section 38a-469 and includes 59
coverage for outpatient prescription drugs. 60
(5) "Health carrier" means an insurance company, health care center, 61
hospital service corporation, medical service corporation, fraternal 62
benefit society or other entity that delivers, issues for delivery, renews, 63
amends or continues a health care plan in this state. 64
(6) "Person" has the same meaning as provided in section 38a-1. 65
(7) "Pharmacist" has the same meaning as provided in section 38a-66
479aaa. 67
(8) "Pharmacist services" has the same meaning as provided in section 68
38a-479aaa. 69
(9) "Pharmacy" has the same meaning as provided in section 38a-70
479aaa. 71
(10) "Pharmacy benefits manager" or "manager" means any person 72
that administers the prescription drug, prescription device, pharmacist 73
services or prescription drug and device and pharmacist services 74
portion of a health care plan on behalf of a health carrier. 75
(11) (A) "Rebate" means a discount or concession, which affects the 76 Substitute Bill No. 5386
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price of an outpatient prescription drug, that a pharmaceutical 77
manufacturer directly provides to a (i) health carrier for an outpatient 78
prescription drug manufactured by the pharmaceutical manufacturer, 79
or (ii) pharmacy benefits manager after the manager processes a claim 80
from a pharmacy or a pharmacist for an outpatient prescription drug 81
manufactured by the pharmaceutical manufacturer. 82
(B) "Rebate" does not mean a bona fide service fee, as such term is 83
defined in Section 447.502 of Title 42 of the Code of Federal Regulations, 84
as amended from time to time. 85
(12) "Specialty drug" means a prescription outpatient specialty drug 86
covered under the Medicare Part D program established pursuant to 87
Public Law 108-173, the Medicare Prescription Drug, Improvement, and 88
Modernization Act of 2003, as amended from time to time, that exceeds 89
the specialty tier cost threshold established by the Centers for Medicare 90
and Medicaid Services. 91
Sec. 4. (NEW) (Effective January 1, 2023) On or after January 1, 2023, 92
each contract entered into between a health carrier and a pharmacy 93
benefits manager that requires the pharmacy benefits manager to 94
administer the prescription drug, prescription device, pharmacist 95
services or prescription drug and device and pharmacist services 96
portion of a health care plan on behalf of the health carrier shall, if the 97
pharmacy benefits manager utilizes a tiered prescription drug 98
formulary, require the pharmacy benefits manager to include at least 99
one covered epinephrine cartridge injector, as defined in section 19a-909 100
of the general statutes, in the cost-sharing tier that imposes the lowest 101
coinsurance, copayment, deductible or other out-of-pocket expense for 102
covered prescription drugs. 103
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2023 New section
Sec. 2 January 1, 2023 New section
Sec. 3 January 1, 2023 38a-479ooo Substitute Bill No. 5386
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Sec. 4 January 1, 2023 New section
INS Joint Favorable Subst.
APP Joint Favorable