HEALTH CARE COVERAGE – PRESCRIPTIONS: This bill would limit the amount a health care service plan, health insurer, or pharmacy benefit manager may require an enrollee or insured to pay at the point of sale for a covered prescription to the lesser of the applicable cost-sharing amount or the retail price. The bill would prohibit a health care service plan, health insurer, or pharmacy benefit manager from requiring a pharmacy to charge or collect a copayment from an enrollee or insured that exceeds the total submitted charges by the network pharmacy. The bill would require the amount paid for a prescription to be applied to the enrollee’s or insured’s deductible and out-of-pocket maximum if the enrollee or insured pays the retail price.

The bill would require a pharmacy to inform a customer whether the retail price for a covered prescription is lower than the applicable cost-sharing amount, unless the pharmacy automatically charges the customer the lower price. If the customer pays the retail price, the bill would require the pharmacy to submit the claim to the health care service plan or health insurer in the same manner as if the customer had purchased the prescription drug by paying the cost-sharing amount when submitted by the network pharmacy. The bill would make a contract provision that is inconsistent with these provisions void and unenforceable.