§ 10-16-104.2 — Coverage for contraception - rules - definitions

Colorado § 10-16-104.2

• Jurisdiction: Colorado
• Title 10: Insurance
• Art.: Health-care Coverage

Text

(1) As used in
this section, unless the context otherwise requires:

(a) Carrier means a carrier offering a health benefit plan.

(b) Contraception has the same meaning as contraceptive or
contraception set forth in section 2-4-401 (1.5).

(c) Dispensing entity means a pharmacy, other outlet, or other facility
registered by the state board of pharmacy under part 1 of article 280 of title 12 that
dispenses or furnishes contraception.

(2) As part of the coverage required for contraception pursuant to section
10-16-104 (3)(a)(I), (18), or (18.1), as applicable, a carrier or a pharmacy benefit
management firm acting on behalf of the carrier shall provide coverage for, and
shall reimburse a provider or an in-network dispensing entity for, the single
dispensing or furnishing of contraception intended to last the covered person for a
duration of twelve months, as permitted by the covered person's prescription,
dispensed or furnished at one time, unless requested otherwise by the covered
person.

(3) A carrier or pharmacy benefit management firm acting on behalf of the
carrier shall:

(a) Allow for the continuous use of clinically appropriate contraception as
determined by the prescribing provider;

(b) Reimburse a provider or an in-network dispensing entity per unit for
dispensing or furnishing contraception;

(c) Not implement step therapy, prior authorization, or other utilization
management practices, including quantity or fill limits, for contraception coverage
if the practice would result in a covered person receiving less than a twelve-months' duration of contraception dispensed or furnished either at one time or, if
requested by the covered person at the point of dispensing or furnishing, over a
twelve-month period;

(d) Include an alternative prescribed contraception without prior
authorization, step therapy, or cost sharing if, in the determination and judgment of
the prescribing provider, the alternative prescribed contraception is medically
necessary;

(e) Make available an easily accessible, timely, and transparent exceptions
process for a covered person to obtain coverage, without cost sharing, for medically
necessary contraception that is not otherwise included in the formulary or available
without cost sharing;

(f) Not require a prescription for coverage of FDA-approved, -cleared, or -granted over-the-counter contraception; and

(g) Include point-of-sale coverage for over-the-counter contraception at in-network dispensing entities without prior authorization, step therapy, utilization
management, or cost sharing.

(4) (a) Carriers shall report annually to the commissioner regarding the
coverage of contraception required pursuant to section 10-16-104 (3)(a)(I), (18), or
(18.1). At a minimum, the reporting requirements must include annual reporting of
data relating to contraception coverage provided in the previous calendar year.

(b) For purposes of the carrier's required reporting to the commissioner
pursuant to subsection (4)(a) of this section, a pharmacy benefit management firm
acting on behalf of a carrier shall annually provide data to the carrier relating to
contraception coverage in the previous calendar year, and the carrier shall include
the data provided by a pharmacy benefit management firm in its annual report
required by subsection (4)(a) of this section.

(5) The commissioner may promulgate rules to implement this section.

Legislative History

Source: L. 2017: Entire section added, (HB 17-1186), ch. 324, p. 1745, � 1, effective January 1, 2019. L. 2019: (2)(a) amended, (HB 19-1172), ch. 136, p. 1654, � 42, effective October 1. L. 2023: Entire section R&RE, (SB 23-284), ch. 276, p. 1629, � 1, effective August 7.