Louisiana Revised Statutes 22:1060.5 – Specialty drug tiers; prohibitions; limits on copayments
Terms Used In Louisiana Revised Statutes 22:1060.5
- 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. A health insurance issuer of a health benefit plan that covers prescription drugs, as defined in La. Rev. Stat. 22:1060.1(8), and utilizes a formulary tier that is higher than a preferred or non-preferred brand drug tier, sometimes known as a specialty drug tier, shall limit any required copayment or coinsurance applicable to drugs on such tier to an amount not to exceed one hundred and fifty dollars per month for each drug up to a thirty-day supply of any single drug. This limit shall be inclusive of any copayment or coinsurance. This limit shall be applicable after any deductible is reached and until the individual’s maximum out-of-pocket limit has been reached.
B. A health care issuer of a health benefit plan that covers prescription drugs, as defined in La. Rev. Stat. 22:1060.1(8), and utilizes specialty tiers shall be required to implement an exceptions process that allows enrollees to request an exception to the formulary. Under such an exception, a non-formulary specialty drug could be deemed covered under the formulary if the prescribing physician determines that the formulary drug for treatment of the same condition either would not be as effective for the individual, would have adverse effects for the individual, or both. In the event an enrollee is denied an exception, such denial shall be considered an adverse event and shall be subject to the health plan internal review process and the state external review process.
C. The provisions of this Section shall not apply to the Office of Group Benefits or to the claims of the Office of Group Benefits enrollees administered by health insurance issuers.
Acts 2014, No. 453, §1, eff. Jan. 1, 2015.