CO| The Amended Regulation 4-2-58 from the Colorado Division of Insurance, establishes new non-discriminatory cost-sharing and tiering requirements for prescription drugs in ACA-compliant individual and small employer health plans, effective May 30, 2025. The regulation aims to ensure fair access to prescription drugs, prevent discriminatory plan designs, and standardize copayment structures across plans.
Key provisions:
- Non-Discriminatory Drug Tiering: Carriers must ensure that no more than 50% of drugs for a specific condition are placed in the highest cost tier, use the latest clinical studies for formulary development, and list all preventive drugs in the first tier with no cost-sharing.
- Copayment-Only Plan Requirements: At least 25% of plans per metal level in each service area must use a copayment-only structure for all drug tiers, with caps on maximum copayments and requirements for meaningful differences between tiers.
- Enforcement and Applicability: The regulation applies to ACA-compliant individual and small group plans (excluding catastrophic, grandfathered, large group, HSA-qualified, and short-term plans), with noncompliance subject to civil penalties, cease and desist orders, or license actions.