{"data":{"id":"us-ky/krs-304.17a-164","jurisdiction":"us-ky","citation":"KRS 304.17A-164","heading":"Limitations on insurers and pharmacy benefit managers regarding","body":"cost-sharing for prescription drugs -- Exceptions.\n(1) As used in this section:\n(a) \"Cost sharing\" means the cost to an insured under a health plan according to\nany coverage limit, copayment, coinsurance, deductible, or other out -of-\npocket expense requirements imposed by the plan, which may be subject to\nannual limitations on cost sharing, including those imposed under 42 U.S.C.\nsecs. 18022(c) and 300gg -6(b), in order for the insured to receive a specific\nhealth care service covered by the plan;\n(b) \"Generic alternative\" means a drug that is designated to be therapeutically\nequivalent by the United States Food and Drug Administration's Approved\nDrug Products with Therapeutic Eq uivalence Evaluations, except that a drug\nshall not be considered a generic alternative until the drug is nationally\navailable;\n(c) \"Health plan\":\n1. Means a policy, contract, certificate, or agreement offered or issued by\nan insurer to provide, deliver, a rrange for, pay for, or reimburse any of\nthe cost of health care services; and\n2. Includes a health benefit plan;\n(d) \"Insured\" means any individual who is enrolled in a health plan and on whose\nbehalf the insurer is obligated to pay for or provide health care services;\n(e) \"Insurer\" includes:\n1. An insurer offering a health plan providing coverage for pharmacy\nbenefits; or\n2. Any other administrator of pharmacy benefits under a health plan;\n(f) \"Person\" means a natural person, corporation, mutual company,\nunincorporated association, partnership, joint venture, limited liability\ncompany, trust, estate, foundation, nonprofit corporation, unincorporated\norganization, government, or governmental subdivision or agency;\n(g) \"Pharmacy\" includes:\n1. A pharmacy, as defined in KRS Chapter 315;\n2. A pharmacist, as defined in KRS Chapter 315; and\n3. Any employee of a pharmacy or pharmacist; and\n(h) \"Pharmacy benefit manager\" has the same meaning as in KRS 304.17A-161.\n(2) To the extent permitted under federal law and except as provided in subsection (4)\nof this section, an insurer issuing or renewing a health plan on or after January 1,\n2022, or a pharmacy benefit manager, shall not:\n(a) Require an insured pur chasing a prescription drug to pay a cost -sharing\namount greater than the amount the insured would pay for the drug if he or\nshe were to purchase the drug without coverage;\n(b) Exclude any cost -sharing amounts paid by an insured or on behalf of an\ninsured by another person for a prescription drug, including any amount paid\nunder paragraph (a) of this subsection, when calculating an insured's\ncontribution to any applicable cost -sharing requirement. The requirements of\nthis paragraph shall not apply:\n1. In the case of a prescription drug for which there is a generic alternative,\nunless the insured has obtained access to the brand prescription drug\nthrough prior authorization, a step therapy protocol, or the insurer's\nexceptions and appeals process; or\n2. To any fully insured health benefit plan or self -insured plan provided to\nany employee under KRS 18A.225;\n(c) Prohibit a pharmacy from discussing any information under subsection (3) of\nthis section; or\n(d) Impose a penalty on a pharmacy for complying with this section.\n(3) A pharmacist shall have the right to provide an insured information regarding the\napplicable limitations on his or her cost sharing pursuant to this section for a\nprescription drug.\n(4) If the application of any requirement of subsection (2)( b) of this section would be\nthe sole cause of a health plan's failure to qualify as a Health Savings Account -\nqualified High Deductible Health Plan under 26 U.S.C. sec. 223, as amended, then\nthe requirement shall not apply to that health plan until the mini mum deductible\nunder 26 U.S.C. sec. 223, as amended, is satisfied.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=54015","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:46Z","sha256":"7ee82baeea92b8442fac87b48545630d6be8d1c90fe77cc6783d6f5eab2cad40","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-1631","next":"us-ky/krs-304.17a-165"},"notice":"GroundRules: Original legal text. Not legal advice."}