(a) Any accident and sickness insurer that utilizes a formulary of medications for which coverage is provided under an individual or group plan master contract shall require any physician or other person authorized by the department of health to prescribe medication to prescribe from the formulary. A physician or other person authorized by the department of health to prescribe medication shall be allowed to prescribe medications previously on, or not on, the accident and sickness insurer’s formulary if he or she believes that the prescription of the non-formulary medication is medically necessary. An accident and sickness insurer shall be required to provide coverage for a non-formulary medication only when the non-formulary medication meets the accident and sickness insurer’s medical exception criteria for the coverage of that medication.
Terms Used In Rhode Island General Laws 27-18-50. Drug coverage
- 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.
- contract: A legal written agreement that becomes binding when signed.
- person: extends to and includes co-partnerships and bodies corporate and politic. See Rhode Island General Laws 43-3-6
(b) An accident and sickness insurer’s medical exception criteria for the coverage of non-formulary medications shall be developed in accordance with § 23-17.13-3(c)(3).
(c) Any subscriber who is aggrieved by a denial of benefits to be provided under this section may appeal the denial in accordance with the rules and regulations promulgated by the department of health pursuant to chapter 17.12 of title 23.
(d) This section shall not apply to insurance coverage providing benefits for: (1) hospital confinement indemnity; (2) disability income; (3) accident only; (4) long term care; (5) Medicare supplement; (6) limited benefit health; (7) specified disease indemnity; (8) sickness or bodily injury or death by accident or both; or (9) other limited benefit policies.
(P.L. 1998, ch. 290, § 1.)