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AN ACT relating to insurance. 1
Be it enacted by the General Assembly of the Commonwealth of Kentucky: 2
Section 1. KRS 304.17A-164 is amended to read as follows: 3
(1) As used in this section: 4
(a) "Cost sharing" means the cost to an[ individual] insured under a health plan 5
according to any coverage limit, copayment, coinsurance, deductible, or other 6
out-of-pocket expense requirements imposed by the plan, which may be 7
subject to annual limitations on cost sharing, including those imposed under 8
42 U.S.C. secs. 18022(c) and 300gg-6(b), in order for the insured[an 9
individual] to receive a specific health care service covered by the plan; 10
(b) "Generic alternative" means a drug that is designated to be therapeutically 11
equivalent by the United States Food and Drug Administration's Approved 12
Drug Products with Therapeutic Equivalence Evaluations, except that a drug 13
shall not be considered a generic alternative until the drug is nationally 14
available; 15
(c) "Health plan": 16
1. Means a policy, contract, certificate, or agreement offered or issued by 17
an insurer to provide, deliver, arrange for, pay for, or reimburse any of 18
the cost of health care services; and 19
2. Includes a health benefit plan[ as defined in KRS 304.17A-005]; 20
(d) "Insured" means any individual who is enrolled in a health plan and on whose 21
behalf the insurer is obligated to pay for or provide health care services; 22
(e) "Insurer" includes: 23
1. An insurer offering a health plan providing coverage for pharmacy 24
benefits; or 25
2. Any other administrator of pharmacy benefits under a health plan; 26
(f) "Person" means a natural person, corporation, mutual company, 27 UNOFFICIAL COPY 23 RS SB 209/GA
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unincorporated association, partnership, joint venture, limited liability 1
company, trust, estate, foundation, nonprofit corporation, unincorporated 2
organization, government, or governmental subdivision or agency; 3
(g) "Pharmacy" includes: 4
1. A pharmacy, as defined in KRS Chapter 315; 5
2. A pharmacist, as defined in KRS Chapter 315; and[or] 6
3. Any employee of a pharmacy or pharmacist; and 7
(h) "Pharmacy benefit manager" has the same meaning as in KRS 304.17A-161. 8
(2) To the extent permitted under federal law and except as provided in subsection (4) 9
of this section, an insurer issuing or renewing a health plan on or after January 1, 10
2022, or a pharmacy benefit manager, shall not: 11
(a) Require an insured purchasing a prescription drug to pay a cost-sharing 12
amount greater than the amount the insured would pay for the drug if he or 13
she were to purchase the drug without coverage; 14
(b) Exclude any cost-sharing amounts paid by an insured or on behalf of an 15
insured by another person for a prescription drug, including any amount paid 16
under paragraph (a) of this subsection, when calculating an insured's 17
contribution to any applicable cost-sharing requirement. The requirements of 18
this paragraph shall not apply: 19
1. In the case of a prescription drug for which there is a generic alternative, 20
unless the insured has obtained access to the brand prescription drug 21
through prior authorization, a step therapy protocol, or the insurer's 22
exceptions and appeals process; or 23
2. To any fully insured health benefit plan or self-insured plan provided 24
to any employee under KRS 18A.225; 25
(c) Prohibit a pharmacy from discussing any information under subsection (3) of 26
this section; or 27 UNOFFICIAL COPY 23 RS SB 209/GA
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(d) Impose a penalty on a pharmacy for complying with this section. 1
(3) A pharmacist shall have the right to provide an insured information regarding the 2
applicable limitations on his or her cost sharing[cost-sharing] pursuant to this 3
section for a prescription drug. 4
(4) If the application of any requirement of subsection (2)(b) of this section would be 5
the sole cause of a health plan's failure to qualify as a Health Savings Account-6
qualified High Deductible Health Plan under 26 U.S.C. sec. 223, as amended, 7
then the requirement shall not apply to that health plan until the minimum 8
deductible under 26 U.S.C. sec. 223, as amended, is satisfied[Subsection (2)(b) of 9
this section shall not apply to any fully insured health benefit plan or self-insured 10
plan provided to an employee under KRS 18A.225]. 11
Section 2. In implementing the requirements of this Act, the state shall only 12
regulate a pharmacy benefit manager or an insurer to the extent permissible under 13
applicable law. 14