COLORADO SUMMARY OF EXISTING LAW

A carrier that has a contract with a pharmacy or pharmacist, or a PBM acting on behalf of a carrier is prohibited from requiring a pharmacy to charge or collect a copayment from a covered person that exceeds the total charges submitted by the network pharmacy.

Beginning January 1, 2021, A contract or agreement, including a performance-based or value-based contract or agreement, between a pharmacy benefit management firm and a pharmacy or a pharmacy services administrative organization with respect to prescription drug benefits administered or managed by the pharmacy benefit management firm must provide that after the date the pharmacy benefit management firm receives a clean claim submitted by a pharmacy, the pharmacy benefit management firm shall not retroactively reduce payment on the claim after the point of sale except as the result of an audit conducted in accordance with the State’s audit law

Link to Existing Law: CO ST § 10-16-122.7 CO ST § 10-16-122.3

PRACTICAL NOTE

This law prevents post-point-of-sale clawbacks when the patient’s copayment amount is greater than the amount the pharmacy stands to retain. The second law prevents a PBM from including post-point of sale fee provisions in contracts with pharmacies. It must be noted that these requirements are limited to insurance plans regulated by the State, and may exclude Medicare Part D and TRICARE plans.