{"data":{"id":"us-ut/utah-code-31a-22-613.5","jurisdiction":"us-ut","citation":"Utah Code § 31A-22-613.5","heading":"Price and value comparisons of health insurance.","body":"(1)\n(a) This section applies to all health benefit plans.\n(b) Subsection (2) applies to:\n(i) all health benefit plans; and\n(ii) coverage offered to state employees under Subsection 49-20-202(1)(a).\n(2) The commissioner shall promote informed consumer behavior and responsible health benefit plans by requiring an insurer issuing a health benefit plan to provide to all enrollees, before enrollment in the health benefit plan, written disclosure of:\n(a) restrictions or limitations on prescription drugs and biologics, including:\n(i) the use of a formulary;\n(ii) co-payments and deductibles for prescription drugs; and\n(iii) requirements for generic substitution;\n(b) coverage limits under the plan;\n(c) any limitation or exclusion of coverage, including:\n(i) a limitation or exclusion for a secondary medical condition related to a limitation or exclusion from coverage; and\n(ii) easily understood examples of a limitation or exclusion of coverage for a secondary medical condition;\n(d)\n(i)\n(A) each drug, device, and covered service that is subject to a preauthorization requirement as defined in Section 31A-22-650; or\n(B) if listing each device or covered service in accordance with Subsection (2)(d)(i)(A) is too numerous to list separately, all devices or covered services in a particular category where all devices or covered services have the same preauthorization requirement;\n(ii) each requirement for authorization as defined in Section 31A-22-650 for:\n(A) each drug, device, or covered service described in Subsection (2)(d)(i)(A); and\n(B) each category of devices or covered services described in Subsection (2)(d)(i)(B); and\n(iii) sufficient information to allow a network provider or enrollee to submit all of the information to the insurer necessary to meet each requirement for authorization described in Subsection (2)(d)(ii);\n(e) whether the insurer permits an exchange of the adoption indemnity benefit in Section 31A-22-610.1 for infertility treatments, in accordance with Subsection 31A-22-610.1(1)(c)(ii) and the terms associated with the exchange of benefits; and\n(f) whether the insurer provides coverage for telehealth services in accordance with Section 26B-3-123 and terms associated with that coverage.\n(3) An insurer shall provide the disclosure required by Subsection (2) in writing to the commissioner:\n(a) upon commencement of operations in the state; and\n(b) anytime the insurer amends any of the following described in Subsection (2):\n(i) treatment policies;\n(ii) practice standards;\n(iii) restrictions;\n(iv) coverage limits of the insurer's health benefit plan or health insurance policy; or\n(v) limitations or exclusions of coverage including a limitation or exclusion for a secondary medical condition related to a limitation or exclusion of the insurer's health insurance plan.\n(4)\n(a) An insurer shall provide the enrollee with notice of an increase in costs for prescription drug coverage due to a change in benefit design under Subsection (2)(a):\n(i) either:\n(A) in writing; or\n(B) on the insurer's website; and\n(ii) at least 30 days prior to the date of the implementation of the increase in cost, or as soon as reasonably possible.\n(b) If under Subsection (2)(a) a formulary is used, the insurer shall make available to prospective enrollees and maintain evidence of the fact of the disclosure of:\n(i) the drugs included;\n(ii) the patented drugs not included;\n(iii) any conditions that exist as a precedent to coverage; and\n(iv) any exclusion from coverage for secondary medical conditions that may result from the use of an excluded drug.\n(c) The commissioner shall develop examples of limitations or exclusions of a secondary medical condition that an insurer may use under Subsection (2)(c).\n(5) Examples of a limitation or exclusion of coverage provided under this section or otherwise are for illustrative purposes only, and the failure of a particular fact situation to fall within the description of an example does not, by itself, support a finding of coverage.\n(6) An insurer shall:\n(a) post the information described in Subsection (2)(d) on the insurer's website and provider portal;\n(b) if requested by an enrollee, provide the enrollee with the information required by this section by mail or email; and\n(c) if requested by a network provider for a specific drug, device, or covered service, provide the network provider with the information described in Subsection (2)(d) for the drug, device, or covered service by mail or email.","path":["Title 31A Insurance Code","Chapter 31A-22 Contracts in Specific Lines","Part 31A-22-6 Accident and Health Insurance"],"source_url":"https://le.utah.gov/xcode/Title31A/Chapter22/31A-22-S613.5.html","current_through":"2026 General Session","vintage":"","retrieved_at":"2026-09-03T11:34:33Z","sha256":"3398d09c85eb9d500e20f568edcca8ad556e2803924e0e848243aaa81379510a","source_id":"us-ut","stale":false,"prev":"us-ut/utah-code-31a-22-613","next":"us-ut/utah-code-31a-22-614"},"notice":"GroundRules: Original legal text. Not legal advice."}