Coverage for contraception - rules - definitions

(a) Carrier means a carrier offering a health benefit plan.

(b) Contraception has the same meaning as contraceptive or contraception set forth in section 2-4-401 (1.5).

(c) Dispensing entity means a pharmacy, other outlet, or other facility registered by the state board of pharmacy under part 1 of article 280 of title 12 that dispenses or furnishes contraception.

(2) As part of the coverage required for contraception pursuant to section 10-16-104 (3)(a)(I), (18), or (18.1), as applicable, a carrier or a pharmacy benefit management firm acting on behalf of the carrier shall provide coverage for, and shall reimburse a provider or an in-network dispensing entity for, the single dispensing or furnishing of contraception intended to last the covered person for a duration of twelve months, as permitted by the covered person's prescription, dispensed or furnished at one time, unless requested otherwise by the covered person.

(3) A carrier or pharmacy benefit management firm acting on behalf of the carrier shall:

(a) Allow for the continuous use of clinically appropriate contraception as determined by the prescribing provider;

(b) Reimburse a provider or an in-network dispensing entity per unit for dispensing or furnishing contraception;

(c) Not implement step therapy, prior authorization, or other utilization management practices, including quantity or fill limits, for contraception coverage if the practice would result in a covered person receiving less than a twelve-months' duration of contraception dispensed or furnished either at one time or, if requested by the covered person at the point of dispensing or furnishing, over a twelve-month period;

(d) Include an alternative prescribed contraception without prior authorization, step therapy, or cost sharing if, in the determination and judgment of the prescribing provider, the alternative prescribed contraception is medically necessary;

(e) Make available an easily accessible, timely, and transparent exceptions process for a covered person to obtain coverage, without cost sharing, for medically necessary contraception that is not otherwise included in the formulary or available without cost sharing;

(f) Not require a prescription for coverage of FDA-approved, -cleared, or -granted over-the-counter contraception; and