(a) When calculating an enrollee’s contribution to an applicable cost sharing requirement, an insurer shall include cost sharing amounts paid by the enrollee or on behalf of the enrollee by another person.

Terms Used In Tennessee Code 56-7-3205

  • Cost sharing requirement: means a copayment, coinsurance, deductible, or annual limitation on cost sharing, including, but not limited to, a limitation subject to 42 U. See Tennessee Code 56-7-3201
  • Generic alternative: means a drug that is designated to be therapeutically equivalent by the United States food and drug administration's Approved Drug Products with Therapeutic Equivalence Evaluations. See Tennessee Code 56-7-3201
  • Person: means any association, aggregate of individuals, business, company, corporation, individual, joint-stock company, Lloyds-type organization, organization, partnership, receiver, reciprocal or interinsurance exchange, trustee or society. See Tennessee Code 56-16-102
  • Prescription drug: means a drug that under federal or state law is required to be dispensed only pursuant to a prescription order or is restricted to use by individuals authorized by law to prescribe drugs. See Tennessee Code 56-7-3201
(b) Subsection (a) does not apply to a prescription drug for which there is a generic alternative, unless the enrollee has obtained access to the brand name prescription drug through prior authorization, a step therapy protocol, the insurer’s exceptions and appeals process, or as specified in § 53-10-204(a).
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