§ 31A-22-643 — Prescription synchronization -- Copay and dispensing fee restrictions -- Rebate requirements -- Pharmacy networks.

Utah § 31A-22-643

• Jurisdiction: Utah
• Title 31A: Insurance Code
• Ch. 31A-22: Contracts in Specific Lines
• Part 31A-22-6: Accident and Health Insurance

Text

(1) For purposes of this section:
(1)(a) "Administrative fee" means the same as that term is defined in Section 31A-46-102.
(1)(b) "Copay" means the copay normally charged for a prescription drug.
(1)(c) "Health insurer" means an insurer, as defined in Subsection 31A-22-634(1).
(1)(d) "Network pharmacy" means a pharmacy included in a health insurance plan's network of pharmacy providers.
(1)(e) "Pharmacy benefit manager" means the same as that term is defined in Section 31A-46-102.
(1)(f) "Prescription drug" means a prescription drug, as defined in Section 58-17b-102, that is prescribed for a chronic condition.
(1)(g) "Rebate" means the same as that term is defined in Section 31A-46-102.
(1)(h) "Standard rebate amount" means a rebate amount that:
(1)(h)(i) is estimated and set by a health benefit plan for a drug product;
(1)(h)(ii) adjusts each quarter based on rebate underpayments or overpayments; and
(1)(h)(iii) is applied when the drug product is dispensed.
(2) A health insurance plan may not charge an amount in excess of the copay for the dispensing of a prescription drug in a quantity less than the prescribed amount if:
(2)(a) the pharmacy dispenses the prescription drug in accordance with the health insurer's synchronization policy; and
(2)(b) the prescription drug is dispensed by a network pharmacy.
(3) A health insurance plan that includes a prescription drug benefit:
(3)(a) shall implement a synchronization policy for the dispensing of prescription drugs to the plan's enrollees; and
(3)(b) may not base the dispensing fee for an individual prescription on the quantity of the prescription drug dispensed to fill or refill the prescription unless otherwise agreed to by the plan and the contracted pharmacy at the time the individual requests synchronization.
(4) (4)(a) A health benefit plan shall ensure that each pharmaceutical manufacturer rebate is used exclusively to benefit enrollees using one or multiple of the following methods:
(4)(a)(i) passing down the rebate to the point of sale to offset an enrollee's deductible or coinsurance;
(4)(a)(ii) using the rebate to reduce premiums paid by the enrollee; or
(4)(a)(iii) using the rebate to enhance enrollee health benefits.
(4)(b) When passing down a rebate as described in Subsection (4)(a)(i), a health benefit plan may:
(4)(b)(i) divide the rebate between the health benefit plan and the enrollee in a manner that is proportional to the enrollee's payment obligation; or
(4)(b)(ii) use a standard rebate amount.
(5) A health benefit plan may not prohibit or condition participation in one pharmacy network on participation in another pharmacy network.
(6) Subsections (4) and (5) apply to a health benefit plan renewed or entered into on or after July 1, 2026.

Legislative History

Amended by Chapter 525, 2025 General Session