A. Each individual and group health maintenance organization contract delivered or issued for delivery in this state that provides a prescription drug benefit shall provide, at a minimum, the following coverage:
(1) at least one product or form of contraception in each of the contraceptive method categories identified by the federal food and drug administration;
(2) a sufficient number and assortment of oral contraceptive pills to reflect the variety of oral contraceptives approved by the federal food and drug administration; and
(3) clinical services related to the provision or use of contraception, including consultations, examinations, procedures, ultrasound, anesthesia, patient education, counseling, device insertion and removal, follow-up care and side-effects management.
B. Except as provided in Subsection C of this section, the coverage required pursuant to this section shall not be subject to:
(1) enrollee cost sharing;
(2) utilization review;
(3) prior authorization or step-therapy requirements; or
(4) any other restrictions or delays on the coverage.
C. A health maintenance organization may discourage brand-name pharmacy drugs or items by applying cost sharing to brand-name drugs or items when at least one generic or therapeutic equivalent is covered within the same method of contraception without patient cost sharing; provided that when an enrollee's health care provider determines that a particular drug or item is medically necessary, the individual or group health maintenance organization contract shall cover the brand-name pharmacy drug or item without cost sharing. Medical necessity may include considerations such as severity of side effects, differences in permanence or reversibility of contraceptives and ability to adhere to the appropriate use of the drug or item, as determined by the attending provider.
D. An individual or group health maintenance organization contract shall grant an enrollee an expedited hearing to appeal any adverse determination made relating to the provisions of this section. The process for requesting an expedited hearing pursuant to this subsection shall:
(1) be easily accessible, transparent, sufficiently expedient and not unduly burdensome on an enrollee, the enrollee's representative or the enrollee's health care provider;
(2) defer to the determination of the enrollee's health care provider; and
(3) provide for a determination of the claim according to a time frame and in a manner that takes into account the nature of the claim and the medical exigencies involved for a claim involving an urgent health care need.
E. An individual or group health maintenance organization contract shall not require a prescription for any drug, item or service that is available without a prescription.
F. An individual or group health maintenance organization contract shall provide coverage and shall reimburse a health care provider or dispensing entity on a per-unit basis for dispensing a six-month supply of contraceptives at one time; provided that the contraceptives are prescribed and self-administered.
G. Nothing in this section shall be construed to:
(1) require a health care provider to prescribe six months of contraceptives at one time; or
(2) permit an individual or group health maintenance organization contract to limit coverage or impose cost sharing for an alternate method of contraception if an enrollee changes contraceptive methods before exhausting a previously dispensed supply.
H. The provisions of this section shall not apply to short-term travel, accident-only, hospital-indemnity-only, limited-benefit or specified disease health benefits plans.
I. The provisions of this section apply to individual or group health maintenance organization contracts delivered or issued for delivery after January 1, 2020.
J. For the purposes of this section:
(1) "contraceptive method categories identified by the federal food and drug administration":
(a) means tubal ligation; sterilization implant; copper intrauterine device; intrauterine device with progestin; implantable rod; contraceptive shot or injection; combined oral contraceptives; extended or continuous use oral contraceptives; progestin-only oral contraceptives; patch; vaginal ring; diaphragm with spermicide; sponge with spermicide; cervical cap with spermicide; male and female condoms; spermicide alone; vasectomy; ulipristal acetate; levonorgestrel emergency contraception; and any additional contraceptive method categories approved by the federal food and drug administration; and
(b) does not mean a product that has been recalled for safety reasons or withdrawn from the market;
(2) "cost sharing" means a deductible, copayment or coinsurance that an enrollee is required to pay in accordance with the terms of an individual or group health maintenance organization contract; and
(3) "health care provider" means an individual licensed to provide health care in the ordinary course of business.
K. A religious entity purchasing individual or group health maintenance organization coverage may elect to exclude prescription contraceptive drugs or devices from the health coverage purchased.
History: Laws 2001, ch. 14, § 3; 2003, ch. 202, § 13; 2019, ch. 263, § 7.
ANNOTATIONSThe 2019 amendment, effective June 14, 2019, required that each individual and group health maintenance organization cover most contraceptive medications and devices free of cost-sharing, and provided that a health maintenance organization may discourage brand-name pharmacy drugs or items by applying cost sharing to brand-name drugs or items when at least one generic or therapeutic equivalent is covered within the same method of contraception without patient cost sharing; in the section heading, deleted "prescription contraceptive drugs or devices" and added "contraception"; in Subsection A, in the introductory clause, deleted "coverage for prescription contraceptive drugs or devices approved by the food and drug administration" and added "at a minimum, the following coverage", and added Paragraphs A(1) through A(3); in Subsection B, deleted "Coverage for food and drug administration-approved prescription contraceptive drugs or devices may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same contract" and added "Except as provided in Subsection C of this section, the coverage required pursuant to this section shall not be subject to", and added Paragraphs B(1) through B(4); and added new Subsections C through J and redesignated former Subsection C as Subsection K.
The 2003 amendment, effective June 20, 2003, in Subsection A, substituted "that provides" for "and which offers" following "in this state" and substituted "provide" for "offer" following "drug benefit shall".