| (a) The formulary information required under this section
must include each prescription drug covered under the plan that is
dispensed in a network pharmacy or administered by a physician or
health care provider and clearly differentiate between drugs covered
under the plan's pharmacy benefits and medical benefits. Information
pertaining to drugs covered under the plan's medical benefits may
be provided as an addendum or link to the formulary and must include
each parameter that is applicable.
(b) The formulary information must include the following
coverage information for each drug:
(1) an explanation of coverage under the health benefit
plan;
(2) an indication of whether the drug is preferred,
if applicable, under the plan;
(3) a disclosure of any prior authorization, step therapy,
or other protocol requirement; and
(4) the specific tier the drug falls under, if the
plan uses a multitier formulary.
(c) The formulary information must include the following
plan-specific cost-sharing information for each drug:
(1) whether the drug is subject to a pharmacy or medical
deductible and where the deductible may be found;
(2) the cost-sharing amount 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:
(A) the dollar amount of a copayment; and
(B) for a drug subject to coinsurance:
(i) an enrollee's cost-sharing amount stated in dollars;
or
(ii) a cost-sharing range denoted as follows:
(I) under $100 - $;
(II) $100 - $250 - $$;
(III) $251 - $500 - $$$;
(IV) $501 - $1,000 - $$$$; or
(V) over $1,000 - $$$$$.
(d) Cost-sharing amounts must reflect the cost to the
consumer, rounded to the next highest dollar amount, for a month-long
supply unless otherwise noted. Cost-sharing information reflecting
the cost for a different duration supply should indicate the applicable
duration. The cost-sharing amount for a given drug must be calculated
based on the plan's median allowed amount or the actual cost for the
drug, using the most up-to-date data available and the cost-sharing
parameters under the enrollee's health benefit plan for the tier under
which the drug is assigned. The information must include whether the
cost-sharing amount is based on the median or the actual cost.
(e) Any formulary information presented using abbreviations
must provide a legend on each page explaining the meaning of each
abbreviation used, including the dollar amounts that correspond to
the cost-sharing range.
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