Louisiana Revised Statutes 22:1060.2 – A health insurance issuer of a health benefit plan that covers prescription drugs and uses one or more drug formularies to specify the prescription drugs covered under the plan shall
Terms Used In Louisiana Revised Statutes 22:1060.2
- Authorized prescriber: means a person licensed, registered, or otherwise authorized by the appropriate licensing board to prescribe prescription drugs in the course of professional practice. See Louisiana Revised Statutes 22:1060.1
- drug: means any of the following:
(a) A substance for which federal or state law requires a prescription before the substance may be legally dispensed to the public. See Louisiana Revised Statutes 22:1060.1
- formulary: means a list of prescription drugs which meets any of the following criteria:
(a) For which a health benefit plan provides coverage. See Louisiana Revised Statutes 22:1060.1
- issuer: means any entity that offers a health benefit plan through a policy, contract, or certificate of insurance subject to state law that regulates the business of insurance. See Louisiana Revised Statutes 22:1060.1
- Physician: means a person licensed by the Louisiana State Board of Medical Examiners. See Louisiana Revised Statutes 22:1060.1
- plan: means an entity which provides benefits through or by a health insurance issuer consisting of health care services provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as health care services under any hospital or medical service policy or certificate, hospital or medical service plan contract, preferred provider organization agreement, or health maintenance organization contract; however, "health benefit plan" shall not include benefits due under Chapter 10 of Title 23 of the Louisiana Revised Statutes of 1950 or limited benefit and supplemental health insurance policies, benefits provided under a separate policy, certificate, or contract of insurance for accidents, disability income, limited scope dental or vision benefits, benefits for long-term care, nursing home care, home health care, or specific diseases or illnesses, or any other limited benefit policy or contract as defined in La. See Louisiana Revised Statutes 22:1060.1
A health insurance issuer of a health benefit plan that covers prescription drugs and uses one or more drug formularies to specify the prescription drugs covered under the plan shall do all of the following:
(1) Provide in plain language in the coverage documentation provided to each enrollee each of the following:
(a) Notice that the plan uses one or more drug formularies.
(b) An explanation of what a drug formulary is.
(c) A statement regarding the method the health insurance issuer uses to determine the prescription drugs to be included in or excluded from a drug formulary.
(d) A statement of how often the health insurance issuer reviews the contents of each drug formulary.
(e) Notice, on a form approved by the Department of Insurance, that an enrollee may contact the health insurance issuer to determine whether a specific drug is included in a particular drug formulary.
(2) Disclose to an individual upon request, not later than the third business day after the date of the request, whether a specific drug is included in a particular drug formulary.
(3) Notify an enrollee and any other individual who requests information pursuant to this Section that the inclusion of a drug in a drug formulary does not guarantee that an enrollee’s physician or other authorized prescriber will prescribe the drug for a particular medical condition or mental illness.
(4)(a) If a prescribed drug is denied based upon the drug’s nonformulary status, provide the prescriber with a list of the alternative comparable formulary medications in writing and attached to the letter of denial of prescription drug coverage.
(b) If a prescribed drug is excluded from coverage under the health benefit plan and other drugs in the same class and used for the same treatment as the excluded drug are covered under the plan, the issuer or its agent shall notify the prescriber of the covered drug.
(c) It shall be deemed sufficient to meet the requirements of this Paragraph if a health benefit plan includes the information required by this Paragraph in the denial letter sent by the health benefit plan or its agent. For any request made by providers utilizing electronic health records with capabilities, the notice may be sent electronically.
(d) Simple notification of the availability and location of the formulary shall not be deemed sufficient to meet the requirements of this Paragraph.
Acts 2011, No. 350, §1, eff. Jan. 1, 2012; Acts 2019, No. 206, §1, eff. Jan. 1, 2020.