§ 20-1126 — Health care insurers; pharmacy benefits managers; cost sharing; calculation; definitions

A. When calculating an enrollee's contribution to any out-of-pocket maximum, deductible, copayment, coinsurance or other applicable cost sharing requirement, the health care insurer that provides pharmacy benefits or a pharmacy benefits manager that administers pharmacy benefits for a health care insurer shall include any cost sharing amount paid by either the enrollee or another person on behalf of the enrollee for a prescription drug that is either:

1. Without a generic equivalent.

2. With a generic equivalent where the enrollee has obtained access to the prescription drug through any of the following:

(a) Prior authorization.

(b) A step therapy protocol.

(c) The health care insurer's exceptions and appeals process.

B. For the purposes of this section:

1. "Generic equivalent":

(a) Means a drug that has an identical amount of the same active chemical ingredients in the same dosage form, that meets applicable standards of strength, quality and purity according to the United States pharmacopeia or other nationally recognized compendium and that, if administered in the same amounts, will provide comparable therapeutic effects.

(b) Does not include a drug that is listed by the United States food and drug administration as having unresolved bioequivalence concerns according to the administration's most recent publication of approved drug products with therapeutic equivalence evaluations.

2. "Health care insurer" has the same meaning prescribed in section 20-1379.