Louisiana Revised Statutes 22:1060.4 – A. The refusal of a health insurance issuer to provide benefits to an enrollee for a prescription drug is an adverse determination for purposes of the Internal Claims and Appeals Pro
Terms Used In Louisiana Revised Statutes 22:1060.4
- 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
- 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. The refusal of a health insurance issuer to provide benefits to an enrollee for a prescription drug is an adverse determination for purposes of the Internal Claims and Appeals Process and External Review Act, La. Rev. Stat. 22:2391 et seq., if each of the following conditions is met:
(1) The drug is not included in a drug formulary used by the health benefit plan.
(2) The enrollee’s physician or other authorized prescriber has determined the drug is medically necessary.
B. The enrollee may appeal the adverse determination pursuant to the Internal Claims and Appeals Process and External Review Act, La. Rev. Stat. 22:2391 et seq.
Acts 2011, No. 350, §1, eff. Jan. 1, 2012; Acts 2016, No. 573, §1, eff. Jan. 1, 2017.