3 Colo. Code Regs. § 702-9-4.2

Current through Register Vol. 47, No. 22, November 25, 2024

Section 3 CCR 702-9-4.2 - Upper Payment Limit Methodology

A.Authority

The statutory authority for this part 4.2 is sections 10-16-1407 and 10-16-1403(5), C.R.S.

B.Scope and Purpose

The purpose of this part 4.2 is to establish the applicability of all upper payment limits for prescription drugs set by the Board pursuant to section 10-16-1407, C.R.S. and part 4.1 of these rules.

C.Applicability of Upper Payment Limits

1. An upper payment limit established by the Board, plus any reasonable fees charged by the pharmacy or pharmacist for dispensing or delivering a prescription drug, applies to a consumer's purchase from a pharmacy (as defined by section 12-280-103(43), C.R.S.) or provider of a prescription drug that is dispensed or administered to the Colorado consumer in person, by mail, or by other means. If the Colorado consumer is insured, the consumer's portion of the payment together with the reimbursement to the pharmacy and provider by the carrier, state entity, or optional participating plan should not exceed the upper payment limit plus any reasonable fees charged by the pharmacy or pharmacist for dispensing or delivering a prescription drug.

2. An upper payment limit established by the Board also applies to any pharmacy (as defined by section 12-280-103(43), C.R.S.) or provider's purchase of a prescription drug that is dispensed or administered to a Colorado consumer in person, by mail, or by other means.

3 CCR 702-9-4.2

45 CR 05, March 10, 2022, effective 3/30/2022

45 CR 18, September 25, 2022, effective 10/15/2022

45 CR 24, December 25, 2022, effective 1/14/2023

46 CR 03, February 10, 2022, effective 3/17/2023