| (a) Except as permitted under subsection (c) of this
section, an issuer of an individual health benefit plan must display
the formulary information required under §21.3032 and §21.3033
of this title (relating to Formulary Disclosure Requirements for Individual
Health Benefit Plans and Facilitating Comparison Shopping for Individual
Health Benefit Plans) on a website that is publicly accessible to
enrollees, prospective enrollees, and others without requiring the
use of paid software, a password, user name, or personally identifiable
information. The formulary information must:
(1) be electronically searchable by drug name; and
(2) use at least 10-point font.
(b) Each summary health plan document must include
a direct electronic link to the website that contains the formulary
information. The direct electronic link must deliver the user directly
to the formulary information associated with the health benefit plan
described by the health plan document, without requiring additional
navigation or user input.
(c) As an alternative to displaying the information
required under §21.3032(c) of this title, alongside the formulary
information required generally under subsection (a) of this section,
an individual health benefit plan issuer may elect to make plan-specific
cost-sharing information available through a web-based tool. A direct
electronic link to the web-based tool must be included on each page
of the formulary disclosure that lists each drug. The purpose of this
alternative method is to encourage the provision of the most timely
and accurate drug price information. In order to qualify for this
alternative method, a web-based tool must:
(1) be publicly accessible to enrollees, prospective
enrollees, and others without requiring the use of paid software or
the necessity of a password, user name, or personally identifiable
information;
(2) allow consumers to electronically search formulary
information by the name under which the health benefit plan is marketed;
(3) include the following plan-specific cost-sharing
information for each drug:
(A) whether the drug is subject to a pharmacy or medical
deductible and where the deductible may be found;
(B) the full price of the drug, based on the plan's
median allowed amount or the actual cost for the drug using the most
up-to-date data available, and a statement as to whether the price
is based on the median or the actual cost;
(C) the cost-sharing amount the enrollee will owe for
each drug under the pharmacy or medical benefit in a retail, mail
order, or physician- or practitioner-administered setting, if applicable,
excluding any deductible requirement, including as applicable:
(i) the dollar amount of a copayment; and
(ii) for a drug subject to coinsurance, the dollar
amount of cost sharing the enrollee will owe, calculated based on
the full price of the drug and the cost-sharing parameters under the
enrollee's health benefit plan for the tier under which the drug is
assigned; and
(4) include, prominently displayed on the web page
under the header "Formulary by Health Benefit Plan," a direct
electronic link to a chart that displays each formulary that applies
to each individual health benefit plan issued by the issuer and includes
a direct electronic link to the Summary of Benefits and Coverage and
formulary document for each health plan listed. This chart may be
limited to health benefit plans being sold in the market in which
the applicable health benefit plan is issued.
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