Amends TCA Title 56, Chapter 7.

Under the present law provisions governing pharmacy benefits, when a patient's out-of-pocket cost for a prescription or covered service is percentage-based, the covered entity or pharmacy benefits manager must calculate the out-of-pocket cost such that when the out-of-pocket cost is added to the amount that the covered entity or pharmacy benefits manager will directly pay to the pharmacy or other dispenser the sum will equal the actual reimbursement.<br /> <br /> This bill adds to the present law provisions governing pharmacy benefits, that when calculating an enrollee's contribution to an applicable cost sharing requirement, an insurer must include cost sharing amounts paid by the enrollee or on behalf of the enrollee by another person. This bill defines "cost sharing requirement" as a copayment, coinsurance, deductible, or annual limitation on cost sharing, including, but not limited to, a limitation subject to federal law, required by, or on behalf of, an enrollee in order to receive a specific healthcare service covered by a health plan, including a prescription drug, whether under the medical or the pharmacy benefit.<br /> <br /> ON APRIL 27, 2021, THE SENATE SUBSTITUTED HOUSE BILL 619 FOR SENATE BILL 1397, ADOPTED AMENDMENT #1, AND PASSED HOUSE BILL 619, AS AMENDED.<br /> <br /> AMENDMENT #1 removes the definitions of "healthcare service" and "health plan", adds a definition of "generic alternative", and adds that this bill's requirement that an insurer shall include cost sharing amounts paid by the enrollee or on behalf of the enrollee by another person when calculating an enrollee's contribution to an applicable cost sharing requirement does not apply to a prescription drug for which there is a generic alternative, unless the enrollee has obtained access to the brand name prescription drug through prior authorization, a step therapy protocol, the insurer's exceptions and appeals process, or as specified in the Tennessee Affordable Drug Act of 2005.<br />