(a) Definitions. — (1) “Carrier” — means any entity that provides health insurance in this State. “Carrier” includes an insurance company, health service corporation, health maintenance organization, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation.
(2) “Contract price” —
means the lowest price a pharmacy is paid for the acquisition of a prescription drug based on a contract that a pharmacy has with a carrier or pharmacy benefits manager. “Contract price” includes a dispensing fee set by a contract between a pharmacy and a carrier or pharmacy benefits manager.
(3) “Pharmacy” —
means as defined in § 2502 of Title 24.
(4) “Pharmacy benefit manager” —
means as defined under § 3302A of this title.
(b) Application. —
This section applies to a carrier that provides coverage, either directly or through a pharmacy benefits manager, for prescription drugs under a health insurance policy or contract that is issued or delivered in this State.
(c) A carrier subject to this section may not impose a copayment or coinsurance requirement for a covered prescription drug that exceeds the lesser of one of the following:
(1) The applicable copayment or coinsurance that would apply for the prescription drug in the absence of this section.
(2) The amount an individual would pay for the prescription drug if the individual were paying the usual and customary price.
(3) The contract price for the prescription drug.
Structure Delaware Code
Chapter 33. HEALTH INSURANCE CONTRACTS
Subchapter I. General Provisions
§ 3303. Scope, format of policy [For application of this section, see 79 Del. Laws, c. 99, § 19].
§ 3304. Required provisions; captions; omissions; substitutions.
§ 3305. Entire contract; changes.
§ 3306. Time limit on certain defenses.
§ 3312. Time of payment of claims.
§ 3314. Physical examination; autopsy.
§ 3316. Change of beneficiary.
§ 3317. Optional policy provisions.
§ 3320. Overinsurance; all coverages.
§ 3321. Relation of earnings to insurance.
§ 3323. Conformity with state statutes.
§ 3325. Intoxicants and narcotics.
§ 3327. Order of certain provisions.
§ 3328. Third-party ownership.
§ 3329. Requirements of other jurisdictions.
§ 3330. Policies issued for delivery in another state.
§ 3331. Conforming to statute.
§ 3334. Franchise health insurance law.
§ 3336. Midwife services reimbursement.
§ 3338. Coverage of cancer monitoring test.
§ 3338A. Equal reimbursement for oral and intravenous anticancer medication.
§ 3340. Child abuse or neglect — Individual coverage.
§ 3341. Newborns and mothers health protection.
§ 3342. Obstetrical and gynecological coverage.
§ 3342A. Contraceptive coverage.
§ 3344. Insurance coverage for diabetes.
§ 3344B. Cost sharing in prescription insulin drugs.
§ 3344C. Coverage for insulin pumps.
§ 3345. Annual pap smear coverage reimbursement.
§ 3346. Colorectal cancer screening.
§ 3347. Required coverage for reconstructive surgery following mastectomies.
§ 3349A. Required coverage for volunteer ambulance company services.
§ 3350. Prescription medication.
§ 3351B. Experimental treatment coverage.
§ 3352. Newborn and infant hearing screening; coverage and reimbursement.
§ 3353. Use of social security numbers on insurance cards.
§ 3355. Phenylketonuria (PKU) and other inherited metabolic diseases.
§ 3356. Required coverage for scalp hair prosthesis.
§ 3358. Dental services for children with a severe disability.
§ 3359. Health insurance; pharmacies; electronic reimbursement.
§ 3359B. Electronic medical (non-pharmaceutical) claims.
§ 3360. Screening of infants and toddlers for developmental delays.
§ 3362. Reimbursement for orthotic and prosthetic services.
§ 3363. Recommended immunizations.
§ 3364. Specialty tier prescription coverage.
§ 3365. School-based health centers.
§ 3366. Autism spectrum disorders coverage.
§ 3367. Payment for emergency medical services.
§ 3370. Telehealth and telemedicine.
§ 3370A. Network disclosure and transparency.
§ 3370C. Time of submitting claim for reimbursement.
§ 3370D. Coverage for epinephrine autoinjectors.
§ 3370E. Annual behavioral health well check [Effective Jan. 1, 2024].