42 U.S.C. § 300gg–19b — Information on prescription drugs

submitted 82 years ago by Pub. L. 115-263 to r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE · 237 words · no verdicts yet

in plain englishAI-generated · not legal advice

Pharmacies can always tell patients if paying cash is cheaper than using insurance. Health plans and their drug-benefit managers can't stop or punish pharmacies for saying so. This protects a patient's true out-of-pocket costs, including deductibles, copays, and coinsurance.

(a) In general. A group health plan or issuer must: (1) not restrict — directly or indirectly — any pharmacy that fills a prescription for an enrollee from telling that enrollee if there's a gap between what they'd pay under the plan and what they'd pay in cash without using any insurance at all. The plan also cannot punish the pharmacy for telling the enrollee this. (2) make sure that any pharmacy benefit manager working under contract for the plan follows this same rule — not restricting or punishing a pharmacy for making that same disclosure. (b) Definition. "Out-of-pocket cost," for getting a drug, means what the enrollee actually pays under the plan — including any deductible, copayment, or coinsurance — plus any other cost the Secretary decides counts.

the actual law source: uscode.house.gov ↗public domain

(a) In general

A group health plan or a health insurance issuer offering group or individual health insurance coverage shall—

(1)

not restrict, directly or indirectly, any pharmacy that dispenses a prescription drug to an enrollee in the plan or coverage from informing (or penalize such pharmacy for informing) an enrollee of any differential between the enrollee’s out-of-pocket cost under the plan or coverage with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any health plan or health insurance coverage; and

(2)

ensure that any entity that provides pharmacy benefits management services under a contract with any such health plan or health insurance coverage does not, with respect to such plan or coverage, restrict, directly or indirectly, a pharmacy that dispenses a prescription drug from informing (or penalize such pharmacy for informing) an enrollee of any differential between the enrollee’s out-of-pocket cost under the plan or coverage with respect to acquisition of the drug and the amount an individual would pay for acquisition of the drug without using any health plan or health insurance coverage.

(b) Definition

For purposes of this section, the term “out-of-pocket cost”, with respect to acquisition of a drug, means the amount to be paid by the enrollee under the plan or coverage, including any cost-sharing (including any deductible, copayment, or coinsurance) and, as determined by the Secretary, any other expenditure.

Source credit: (July 1, 1944, ch. 373, title XXVII, § 2729, as added Pub. L. 115–263, § 2, Oct. 10, 2018, 132 Stat. 3672.)

history & why it existsrecord from the source credit

1944Enacted · Pub. L. 115-263 · 132 Stat. 3672

A history note hasn’t been published yet. The record shows enactment by Pub. L. 115-263 on 1944-07-01.

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