Delaware Code Title 18 Sec. 3566A – Copayment or coinsurance for prescription drugs limited
(a) Definitions. — (1) “Carrier” means any entity that provides health insurance in this State. “Carrier” includes an insurance company, health service corporation, health maintenance organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation.
(2) “Contract price” means the lowest price a pharmacy is paid for the acquisition of a prescription drug based on a contract that a pharmacy has with a carrier or pharmacy benefits manager. “Contract price” includes a dispensing fee set by a contract between a pharmacy and a carrier or pharmacy benefits manager.
(3) “Cost-sharing requirement” means any copayment, coinsurance, deductible, or annual limitation on cost-sharing (including a limitation subject to 42 U.S.C. §§ 18022(c) and 300gg-6(b)), required by or on behalf of an enrollee in order to receive a specific health care service, including a prescription drug, covered by a health benefit plan.
(4) “Health benefit plan” means as defined in § 3343 of this title.
(5) “Health care service” means an item or service furnished to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability.
(6) “Person” means as defined in § 102 of this Title.
(7) “Pharmacy” means as defined in § 2502 of Title 24.
(8) “Pharmacy benefit manager” means as defined under § 3302A of this title.
Terms Used In Delaware Code Title 18 Sec. 3566A
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- State: means the State of Delaware; and when applied to different parts of the United States, it includes the District of Columbia and the several territories and possessions of the United States. See Delaware Code Title 1 Sec. 302
(b) Application. —
This section applies to a carrier that provides coverage, either directly or through a pharmacy benefits manager, for prescription drugs under a health insurance policy, health benefit plan, or contract that is issued or delivered in this State.
(c) A carrier subject to this section may not impose a copayment or coinsurance requirement for a covered prescription drug that exceeds the lesser of one of the following:
(1) The applicable copayment or coinsurance that would apply for the prescription drug in the absence of this section.
(2) The amount an individual would pay for the prescription drug if the individual were paying the usual and customary price.
(3) The contract price for the prescription drug.
(d) Cost-sharing calculation. —
When calculating an enrollee contribution to any applicable cost-sharing requirement, a carrier shall include any cost-sharing amounts paid by the enrollee or on behalf of the enrollee by another person. If under federal law, application of this requirement would result in health savings account ineligibility under § 223 of the federal Internal Revenue Code [26 U.S.C. § 223], this requirement shall apply for health savings account-qualified high deductible health plans with respect to the deductible of such a plan after the enrollee has satisfied the minimum deductible under [26 U.S.C.] § 223, except with respect to items or services that are preventive care pursuant to [26 U.S.C.] § 223(c)(2)(C) of the federal Internal Revenue Code, in which case the requirements of this subsection shall apply regardless of whether the minimum deductible under [26 U.S.C.] § 223 has been satisfied.
(e) Rule-making. —
The Insurance Commissioner may promulgate rules and regulations as may be necessary or appropriate to implement and administer this section.