§ 4089i. Prescription drug coverage

(a) A health insurance or other health benefit plan offered by a health insurer shall provide coverage for prescription drugs purchased in Canada, and used in Canada or reimported legally or purchased through the I-SaveRx program on the same benefit terms and conditions as prescription drugs purchased in this country. For drugs purchased by mail or through the Internet, the plan may require accreditation by the Internet and Mailorder Pharmacy Accreditation Commission (IMPAC/tm) or similar organization.

(b) A health insurance or other health benefit plan offered by a health insurer or pharmacy benefit manager shall not include an annual dollar limit on prescription drug benefits.

(c) A health insurance or other health benefit plan offered by a health insurer or pharmacy benefit manager shall limit a beneficiary‘s out-of-pocket expenditures for prescription drugs, including specialty drugs, to no more for self-only and family coverage per year than the minimum dollar amounts in effect under Section 223(c)(2)(A)(i) of the Internal Revenue Code of 1986 for self-only and family coverage, respectively.

(d) For prescription drug benefits offered in conjunction with a high-deductible health plan (HDHP), the plan may not provide prescription drug benefits until the expenditures applicable to the deductible under the HDHP have met the amount of the minimum annual deductibles in effect for self-only and family coverage under Section 223(c)(2)(A)(i) of the Internal Revenue Code of 1986 for self-only and family coverage, respectively, except that a plan may offer first-dollar prescription drug benefits to the extent permitted under federal law. Once the foregoing expenditure amount has been met under the HDHP, coverage for prescription drug benefits shall begin, and the limit on out-of-pocket expenditures for prescription drug benefits shall be as specified in subsection (c) of this section.

(e)(1) A health insurance or other health benefit plan offered by a health insurer or by a pharmacy benefit manager on behalf of a health insurer that provides coverage for prescription drugs and uses step-therapy protocols shall not require failure on the same medication on more than one occasion for continuously enrolled members or subscribers.

(2) Nothing in this subsection shall be construed to prohibit the use of tiered co-payments for members or subscribers not subject to a step-therapy protocol.

(3) Notwithstanding subdivision (1) of this subsection, a health insurance or other health benefit plan offered by an insurer or by a pharmacy benefit manager on behalf of a health insurer that provides coverage for prescription drugs shall not utilize a step-therapy, “fail first,” or other protocol that requires documented trials of a medication, including a trial documented through a “MedWatch” (FDA Form 3500), before approving a prescription for the treatment of substance use disorder.

(f)(1) A health insurance or other health benefit plan offered by a health insurer or by a pharmacy benefit manager on behalf of a health insurer that provides coverage for prescription drugs shall not require, as a condition of coverage, use of drugs not indicated by the federal Food and Drug Administration for the condition diagnosed and being treated under supervision of a health care professional.

(2) Nothing in this subsection shall be construed to prevent a health care professional from prescribing a medication for off-label use.

(g) A health insurance or other health benefit plan offered by a health insurer or by a pharmacy benefit manager on behalf of a health insurer that provides coverage for prescription drugs shall apply the same cost-sharing requirements to interchangeable biological products as apply to generic drugs under the plan.

(h)(1) A health insurance or other health benefit plan offered by a health insurer or pharmacy benefit manager shall limit a beneficiary’s total out-of-pocket responsibility for prescription insulin medications to not more than $100.00 per 30-day supply, regardless of the amount, type, or number of insulin medications prescribed for the beneficiary.

(2) The $100.00 monthly limit on out-of-pocket spending for prescription insulin medications set forth in subdivision (1) of this subsection shall apply regardless of whether the beneficiary has satisfied any applicable deductible requirement under the health insurance or health benefit plan.

(i) As used in this section:

(1) “Health care professional” means an individual licensed to practice medicine under 26 Vt. Stat. Ann. chapter 23 or 33, an individual licensed as a physician assistant under 26 Vt. Stat. Ann. chapter 31, or an individual licensed as an advanced practice registered nurse under 26 Vt. Stat. Ann. chapter 28.

(2) “Health insurer” shall have the same meaning as in 18 V.S.A. § 9402.

(3) “Out-of-pocket expenditure” means a co-payment, coinsurance, deductible, or other cost-sharing mechanism.

(4) “Pharmacy benefit manager” shall have the same meaning as in section 4089j of this title.

(5) “Step therapy” means protocols that establish the specific sequence in which prescription drugs for a specific medical condition are to be prescribed.

(6) “Interchangeable biological products” shall have the same meaning as in 18 V.S.A. § 4601.

(7) “Prescription insulin medication” means a prescription medication that contains insulin and is used to treat diabetes.

(j) The Department of Financial Regulation shall enforce this section and may adopt rules as necessary to carry out the purposes of this section. (Added 2003, No. 122 (Adj. Sess.), § 128l; amended 2005, No. 2, § 5, eff. Feb. 17, 2005; 2011, No. 171 (Adj. Sess.), § 32; 2013, No. 79, § 3; 2017, No. 193 (Adj. Sess.), § 6; 2019, No. 154 (Adj. Sess.), § E.307.1, eff. Jan. 1, 2022; 2023, No. 22, § 6, eff. May 25, 2023.)