02b. Calculation of member's contributions for a prescription drug covered under the health benefit plan. (a) Except as otherwise provided in subsection (b) of this section, when calculating a member's contribution to their coinsurance, copayment, cost-sharing responsibility, deductible, or out-of-pocket maximum under the member's health benefit plan, the health insurer shall include any discount, financial assistance payment, product voucher, or any other out-of-pocket expense made by or on behalf of the member for a prescription drug covered under the member's health benefit plan that: (1) Is without a generic drug equivalent or an interchangeable biological product preferred under the health benefit plan's formulary; or (2) Has a generic equivalent drug or an interchangeable biological product preferred under the health benefit plan's formulary where the member has obtained access to the drug through prior authorization, a step therapy protocol, or the exception or appeal process of the health insurer or pharmacy benefits manager. (b) Subsection (a) of this section shall not apply to a member covered by a high deductible health plan, as that term is defined under 26 l process of the health insurer or pharmacy benefits manager. (b) Subsection (a) of this section shall not apply to a member covered by a high deductible health plan, as that term is defined under 26 U.S.C. § 223, until the member satisfies their minimum deductible; except, that subsection (a) of this section shall apply to contribution amounts made for preventative care, as that term is defined under 26 U.S.C. § 223(c)(2)(C). (c) This section shall apply to health benefit plans entered into, amended, extended, or renewed on or after January 1, 2025. (Apr. 17, 2017, D.C. Law 21-248, § 3b; as added July 20, 2023, D.C. Law 25-26, § 2(b), 70 DCR 7912.)
District of Columbia Legal Code