02-11 15:21 2nd Sub. (Gray) H.B. 52
Candice B. Pierucci proposes the following substitute bill:
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Health Insurance Modifications
2025 GENERAL SESSION
STATE OF UTAH
Chief Sponsor: Candice B. Pierucci
Senate Sponsor:
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LONG TITLE
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General Description:
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This bill enacts provisions related to health insurance.
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Highlighted Provisions:
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This bill:
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▸ defines terms;
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▸ requires an insurer to calculate drug or device discount coupons on behalf of an individual
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towards the individual's cost sharing requirement unless certain circumstances are met;
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▸ requires a entity that provides a drug or device discount coupon to allow the full amount
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of the coupon amount to be used for the drug or device; and
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▸ provides an exception to the requirements for a qualifying health benefit plan.
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Money Appropriated in this Bill:
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None
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Other Special Clauses:
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None
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Utah Code Sections Affected:
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ENACTS:
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31A-22-662, Utah Code Annotated 1953
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31A-48-104, Utah Code Annotated 1953
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Be it enacted by the Legislature of the state of Utah:
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Section 1. Section 31A-22-662 is enacted to read:
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31A-22-662 . Cost sharing requirements for health benefit plans.
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(1) As used in this section:
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(a) "Biosimilar" means a biological product, as defined in 42 U.S.C. Sec. 262, that is
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highly similar to another biological product.
2nd Sub. H.B. 52 2nd Sub. (Gray) H.B. 52 02-11 15:21
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(b)(i) "Cost sharing requirement" means any copayment, coinsurance, deductible, or
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annual limitation on cost sharing required by a health benefit plan for a specific
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health care service covered by the health benefit plan.
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(ii) "Cost sharing requirement" includes any copayment, coinsurance, deductible, or
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annual limitation that is subject to 42 U.S.C. Sec. 18022(c) or 300gg-6(b).
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(c) "Qualifying health benefit plan" means a health benefit plan that:
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(i) allows the full value of available copay assistance to reduce the out-of-pocket
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costs of an enrollee;
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(ii) includes, when two or more individuals are covered, an individual maximum
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out-of-pocket that is not greater than 50% of the health benefit plan's combined
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total maximum out-of-pocket for family coverage;
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(iii) after the deductible has been met, only requires payment by the enrollee at the
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equivalent of the plan's lowest payment tier for any drug that has been subject to
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copay assistance and that copay assistance has been exhausted; and
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(iv) for a covered lower cost drug that an enrollee is required to take under the plan
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instead of a covered higher cost drug for which copay assistance reduces the
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enrollee's out-of-pocket costs to a negligible amount, the plan:
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(A) only requires payment by the enrollee of the preferred drug at the equivalent
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of the plan's lowest payment tier; and
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(B) may share cost savings due to the lower cost drug with the enrollee, including
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while the enrollee is subject to a deductible.
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(2) Except as provided in Subsection (3), when calculating an enrollee's contribution to any
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applicable cost sharing requirement for a covered prescription drug or device, an insurer
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shall include any cost sharing amounts paid:
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(a) by the enrollee; or
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(b) using a drug discount coupon.
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(3) An insurer may refuse to apply a drug discount coupon to an enrollee's applicable cost
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sharing requirement for the drug or device that is eligible for the drug discount coupon if:
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(a) the drug or device that is eligible for the drug discount coupon has:
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(i) a generic alternative; or
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(ii) a biosimilar that:
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(A) has been approved by the federal Food and Drug Administration to treat the
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enrollee's condition;
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(B) is not eligible for a drug discount coupon; and
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(C) is subject to the health benefit plan's lowest copay tier for biologic products; or
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(b) the enrollee has not obtained a necessary approval from the health benefit plan to
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have the drug covered by the health benefit plan or has not completed the necessary
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requirements, restrictions, or clinical criteria to obtain the approval.
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(4) This section:
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(a) applies to any health benefit plan entered into, amended, extended, or renewed on or
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after July 1, 2026; and
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(b) does not apply to a qualifying health benefit plan.
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(5) The commissioner may make rules in accordance with Title 63G, Chapter 3, Utah
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Administrative Rulemaking Act, to implement this section.
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(6) The department shall enforce this section within existing appropriations.
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Section 2. Section 31A-48-104 is enacted to read:
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31A-48-104 . Drug discount coupon requirements.
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(1) As used in this section, "cost sharing requirement" means the same as that term is
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defined in Section 31A-22-662.
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(2) A pharmaceutical manufacturer or other entity that provides a drug discount coupon
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with the expectation that the drug discount coupon will be applied toward an enrollee's
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cost sharing requirement:
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(a) shall allow an insurer, complying with Section 31A-22-662, to utilize the full value
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of the drug discount coupon:
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(i) first to reduce the enrollee's cost sharing requirement, including the enrollee's
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maximum out-of-pocket expense, at the point of sale; and
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(ii) for any remainder, to lower the cost of the prescription drug or device;
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(b) shall disclose to the insurer the terms and conditions associated with the drug
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discount coupon at least 12 months before a drug discount coupon is issued; and
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(c) may not modify the terms and conditions associated with the drug discount coupon
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on the basis that it is redeemed by an enrollee of the health benefit plan that is
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complying with Section 31A-22-662.
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(3) The department shall enforce this section within existing appropriations.
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Section 3. Effective Date.
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This bill takes effect on May 7, 2025.
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