Louisiana Revised Statutes 22:1060.3 – A. A health insurance issuer of a health benefit plan that covers prescription drugs shall offer to each enrollee at the contracted benefit level and until the enrollee’s plan renewa
Terms Used In Louisiana Revised Statutes 22:1060.3
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- 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
- insured: means an individual who is enrolled or insured by a health insurance issuer under a health benefit plan. 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. A health insurance issuer of a health benefit plan that covers prescription drugs shall offer to each enrollee at the contracted benefit level and until the enrollee’s plan renewal date any prescription drug that was approved or covered under the plan for a medical condition or medical illness, regardless of whether the drug has been removed from the health benefit plan’s drug formulary before the plan renewal date. Nothing herein shall prohibit the health insurance issuer from providing information to the enrollee regarding alternative covered drugs.
B. This Section shall not prohibit a physician or other authorized prescriber from prescribing a drug that is an alternative to a drug for which continuation of coverage is required by Subsection A of this Section if the alternative drug meets each of the following conditions:
(1) The drug is covered under the health benefit plan.
(2) The drug is medically appropriate for the enrollee.
C.(1) A health insurance issuer proposing to change its coverage of a particular prescription drug or intravenous infusion based on medical necessity shall give notice of the proposed change to an insured currently using that prescription drug or intravenous infusion who the health insurance issuer determines the change may affect if the health insurance issuer has covered the drug or intravenous infusion for the insured for at least the preceding sixty days. Such notice shall be sent at least sixty days prior to the effective date of the proposed change.
(2) Any insured receiving such a notice from a health insurance issuer shall have the right to appeal the proposed change during the sixty-day notification period provided for in Paragraph (1) of this Subsection in accordance with the Internal Claims and Appeals Process and External Review Act, La. Rev. Stat. 22:2391 et seq. In filing such an appeal, the insured shall document that his physician or authorized prescriber considers continued use of the drug or intravenous infusion to be medically necessary.
Acts 2011, No. 350, §1, eff. Jan. 1, 2012; Acts 2012, No. 316, §1, eff. May 25, 2012; Acts 2016, No. 573, §1, eff. Jan. 1, 2017.