Utah Admin. Code R590-200-4 - Minimum Standards and General Provisions

(1) Coverage for diabetes treatment is subject to the deductibles, copayments, out-of-pocket maximums, and coinsurance of the policy.

(2)

(a) An accident and health insurance policy that provides a health insurance benefit shall cover diabetes self-management training and patient management, including medical nutrition therapy, when medically necessary and prescribed by a physician.

(b) The diabetes self-management training services must be provided by a diabetes self-management training program:

(i) recognized by the Centers for Medicare and Medicaid Services;

(ii) certified by the Utah Department of Health and Human Services; or

(iii) approved or accredited by a national organization certifying standards of quality in the provision of diabetes self-management education.

(c) A diabetes self-management training program shall be provided upon:

(i) a diagnosis with diabetes;

(ii) a significant change in a diabetes-related condition;

(iii) a change in diagnostic levels; or

(iv) a change in treatment regimen.

(3) An accident and health insurance policy that provides a health insurance benefit shall cover the following when medically necessary:

(a) blood glucose monitors designed for diabetic patients;

(b) blood glucose monitors for the legally blind designed for use with adaptive devices;

(c) test strips for glucose monitors, including test strips cleared by the FDA;

(d) visual reading strips for glucose and ketones;

(e) urine testing strips for glucose and ketones;

(f) lancet devices and lancets for monitoring glycemic control;

(g) insulin, including analog, in either vial or cartridge;

(h) injection aids, including those adaptable to meet the needs of the legally blind;

(i) syringes, including insulin syringes, pen-like insulin injection devices, needles for pen-like insulin injection devices, and other disposable parts required for insulin injection aids;

(j) insulin pumps, including insulin infusion pumps;

(k) medical supplies for use:

(i) with insulin pumps and insulin infusion pumps, including infusion sets, cartridges, syringes, skin preparation, batteries, and other disposable supplies needed to maintain insulin pump therapy; and

(ii) with or without insulin pumps and insulin infusion pumps, including durable and disposable devices for the injection of insulin and infusion sets;

(l) prescription oral agents of each class approved by the FDA for treatment of diabetes, and a variety of drugs, when available, within each class; and

(m) glucagon kits.

(4)

(a) No later than June 1 each year, the department shall publish on the department's website at www.insurance.utah.gov:

(i) the price of insulin available under the discount program described in Section 49-20-421;

(ii) the insulin prescription caps for the following calendar year; and

(iii) the average wholesale price of insulin per milliliter, AWP/mL, for each calendar year 2019 and later.

(b) The insulin prescription caps are calculated using data provided by Public Employees Health Plan (PEHP) based on the annual change in the average AWP/mL.

(i) The calculation considers the following initial reference values:

(A) PEHP's average insulin AWP/mL in 2019 of $40.18, Base AWP/mL;

(B) the 2021 insulin prescription cap in Subsection 31A-22-626(4)(a) of $30, Base Low Cap; and

(C) the 2021 insulin prescription cap in Subsection 31A-22-626(6)(b) of $100, Base High Cap.

(ii)

(A) The insulin prescription cap is rounded to the nearest dollar.

(B) Effective for plan years on or after January 1, 2025, the insulin prescription cap is rounded down to the nearest multiple of $5.

(c)

(i) The insulin prescription cap formula for years after 2021 for Subsection 31A-22-626(4)(a) is: Year X low cap = (Average AWP/mL for Year X-2 / Base AWP/mL) * (Base Low Cap) rounded to the nearest dollar.

(ii) The insulin prescription cap formula for years after 2024 for Subsection 31A-22-626(4)(a) is rounded down to the nearest multiple of $5.

(d)

(i) The insulin prescription cap formula for years after 2021 for Subsection 31A-22-626(6)(b) is: Year X high cap = (Average AWP/mL for Year X-2 / Base AWP/mL) * (Base High Cap) rounded to the nearest dollar.

(ii) The insulin prescription cap formula for years after 2024 for Subsection 31A-22-626(6)(b) is rounded down to the nearest multiple of $5.

(e) The adjusted insulin prescription cap posted on June 1 takes effect for a policy issued or renewed on or after January 1 of the following calendar year.

Notes

Utah Admin. Code R590-200-4

Repealed by Utah State Bulletin Number 2022-11, effective 5/11/2022 Amended by Utah State Bulletin Number 2024-12, effective 6/7/2024