§ 26.1-36-09.16 — Health insurance benefits coverage - Insulin drug and supply out-of-pocket limitations

North Dakota § 26.1-36-09.16

• Jurisdiction: North Dakota
• Title 26.1: Insurance
• Ch. 26.1-36: Accident and Health Insurance

Text

pocket limitations.
1. As used in this section:
a. "Health benefit plan" has the same meaning as in section 26.1-36.3-01.
b. "Insulin drug" means a prescription drug that contains insulin and is used to treat
a form of diabetes mellitus. The term does not include an insulin pump, an
electronic insulin-administering smart pen, or a continuous glucose monitor, or
supplies needed specifically for the use of such electronic devices. The term
includes insulin in the following categories:
(1) Rapid-acting insulin;
(2) Short-acting insulin;
(3) Intermediate-acting insulin;
(4) Long-acting insulin;
(5) Premixed insulin product;
(6) Premixed insulin/GLP-1 RA product; and
(7) Concentrated human regular insulin.
c. "Medical supplies for insulin dosing and administration" means supplies needed
for proper insulin dosing, as well as supplies needed to detect or address medical
emergencies in an individual using insulin to manage diabetes mellitus. The term
does not include an insulin pump, an electronic insulin-administering smart pen,
or a continuous glucose monitor, or supplies needed specifically for the use of
such electronic devices. The term includes:
(1) Blood glucose meters;
(2) Blood glucose test strips;
(3) Lancing devices and lancets;
(4) Ketone testing supplies, such as urine strips, blood ketone meters, and
blood ketone strips;
(5) Glucagon, in injectable and nasal forms;

(6) Insulin pen needles; and
(7) Insulin syringes.
d. "Pharmacy or distributor" means a pharmacy or medical supply company, or
other medication or medical supply distributor filling a prescription.
2. An insurance company, nonprofit health service corporation, or health maintenance
organization may not deliver, issue, execute, or renew any health benefit plan unless
the health benefit plan provides benefits for insulin drug and medical supplies for
insulin dosing and administration which complies with this section.
3. The health benefit plan must limit out-of-pocket costs for a thirty-day supply of:
a. Covered insulin drugs, which may not exceed twenty-five dollars per pharmacy or
distributor, regardless of the quantity or type of insulin drug used to fill the
covered individual's prescription needs.
b. Covered medical supplies for insulin dosing and administration, the total of which
may not exceed twenty-five dollars per pharmacy or distributor, regardless of the
quantity or manufacturer of supplies used to fill the covered individual's
prescription needs.
4. The health benefit plan may not allow a pharmacy benefits manager or the pharmacy
or distributor to charge a covered individual, require the pharmacy or distributor to
collect from a covered individual, or require a covered individual to make a payment
for a covered insulin drug or medical supplies for insulin dosing and administration in
an amount exceeding the out-of-pocket limits under subsection 3.
5. The health benefit plan may not impose a deductible, copayment, coinsurance, or
other cost-sharing requirement that causes out-of-pocket costs for prescribed insulin
or medical supplies for insulin dosing and administration to exceed the amount under
subsection 3.
6. Subsection 3 does not require the health benefit plan to implement a particular cost-
sharing structure and does not prevent the limitation of out-of-pocket costs to less than
the amount specified under subsection 3. This section does not limit whether the
health benefit plan classifies an insulin pump, an electronic insulin-administering smart
pen, or a continuous glucose monitor as a drug or as a medical device or supply.
7. If application of subsection 3 would result in the ineligibility of a health benefit plan that
is a qualified high-deductible health plan to qualify as a health savings account under
section 223 of the Internal Revenue Code [26 U.S.C. 223], the requirements of
subsection 3 do not apply with respect to the deductible of the health benefit plan until
after the enrollee has met the minimum deductible under section 26 U.S.C. 223.
8. This section does not apply to the Medicare part D prescription drug coverage plan.