(1)(1)(a) This section applies to all health benefit plans.
(1)(b) Subsection (2) applies to:
(1)(b)(i) all health benefit plans; and
(1)(b)(ii) coverage offered to state employees under Subsection 49-20-202(1)(a).
(2)The commissioner shall promote informed consumer behavior and responsible health benefit plans by requiring an insurer issuing a health benefit plan to provide to all enrollees, before enrollment in the health benefit plan, written disclosure of:
(2)(a) restrictions or limitations on prescription drugs and biologics, including:
(2)(a)(i) the use of a formulary;
(2)(a)(ii) co-payments and deductibles for prescription drugs; and
(2)(a)(iii) requirements for generic substitution;
(2)(b) coverage limits under the plan;
(2)(c) any limitation or exclusion of coverage, including:
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(1) (1)(a) This section applies to all health benefit plans.
(1)(b) Subsection (2) applies to:
(1)(b)(i) all health benefit plans; and
(1)(b)(ii) coverage offered to state employees under Subsection 49-20-202(1)(a).
(2) The commissioner shall promote informed consumer behavior and responsible health benefit plans by requiring an insurer issuing a health benefit plan to provide to all enrollees, before enrollment in the health benefit plan, written disclosure of:
(2)(a) restrictions or limitations on prescription drugs and biologics, including:
(2)(a)(i) the use of a formulary;
(2)(a)(ii) co-payments and deductibles for prescription drugs; and
(2)(a)(iii) requirements for generic substitution;
(2)(b) coverage limits under the plan;
(2)(c) any limitation or exclusion of coverage, including:
(2)(c)(i) a limitation or exclusion for a secondary medical condition related to a limitation or exclusion from coverage; and
(2)(c)(ii) easily understood examples of a limitation or exclusion of coverage for a secondary medical condition;
(2)(d) (2)(d)(i) (2)(d)(i)(A) each drug, device, and covered service that is subject to a preauthorization requirement as defined in Section 31A-22-650; or
(2)(d)(i)(B) if listing each device or covered service in accordance with Subsection (2)(d)(i)(A) is too numerous to list separately, all devices or covered services in a particular category where all devices or covered services have the same preauthorization requirement;
(2)(d)(ii) each requirement for authorization as defined in Section 31A-22-650 for:
(2)(d)(ii)(A) each drug, device, or covered service described in Subsection (2)(d)(i)(A); and
(2)(d)(ii)(B) each category of devices or covered services described in Subsection (2)(d)(i)(B); and
(2)(d)(iii) sufficient information to allow a network provider or enrollee to submit all of the information to the insurer necessary to meet each requirement for authorization described in Subsection (2)(d)(ii);
(2)(e) whether the insurer permits an exchange of the adoption indemnity benefit in Section 31A-22-610.1 for infertility treatments, in accordance with Subsection 31A-22-610.1(1)(c)(ii) and the terms associated with the exchange of benefits; and
(2)(f) whether the insurer provides coverage for telehealth services in accordance with Section 26B-3-123 and terms associated with that coverage.
(3) An insurer shall provide the disclosure required by Subsection (2) in writing to the commissioner:
(3)(a) upon commencement of operations in the state; and
(3)(b) anytime the insurer amends any of the following described in Subsection (2):
(3)(b)(i) treatment policies;
(3)(b)(ii) practice standards;
(3)(b)(iii) restrictions;
(3)(b)(iv) coverage limits of the insurer's health benefit plan or health insurance policy; or
(3)(b)(v) limitations or exclusions of coverage including a limitation or exclusion for a secondary medical condition related to a limitation or exclusion of the insurer's health insurance plan.
(4) (4)(a) An insurer shall provide the enrollee with notice of an increase in costs for prescription drug coverage due to a change in benefit design under Subsection (2)(a):
(4)(a)(i) either:
(4)(a)(i)(A) in writing; or
(4)(a)(i)(B) on the insurer's website; and
(4)(a)(ii) at least 30 days prior to the date of the implementation of the increase in cost, or as soon as reasonably possible.
(4)(b) If under Subsection (2)(a) a formulary is used, the insurer shall make available to prospective enrollees and maintain evidence of the fact of the disclosure of:
(4)(b)(i) the drugs included;
(4)(b)(ii) the patented drugs not included;
(4)(b)(iii) any conditions that exist as a precedent to coverage; and
(4)(b)(iv) any exclusion from coverage for secondary medical conditions that may result from the use of an excluded drug.
(4)(c) The commissioner shall develop examples of limitations or exclusions of a secondary medical condition that an insurer may use under Subsection (2)(c).
(5) Examples of a limitation or exclusion of coverage provided under this section or otherwise are for illustrative purposes only, and the failure of a particular fact situation to fall within the description of an example does not, by itself, support a finding of coverage.
(6) An insurer shall:
(6)(a) post the information described in Subsection (2)(d) on the insurer's website and provider portal;
(6)(b) if requested by an enrollee, provide the enrollee with the information required by this section by mail or email; and
(6)(c) if requested by a network provider for a specific drug, device, or covered service, provide the network provider with the information described in Subsection (2)(d) for the drug, device, or covered service by mail or email.