(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 v2. 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) Prior to removing a prescription drug from its plan’s formulary or making any change in the preferred or tiered, cost-sharing status of a covered prescription drug, an accident and sickness insurer must provide at least thirty (30) days’ notice to authorized prescribers by established communication methods of policy and program updates and by updating available references on web-based publications. All affected members must be provided at least thirty (30) days’ notice prior to the date such change becomes effective by a direct notification:
(i) The written or electronic notice must contain the following information:
(A) The name of the affected prescription drug;
(B) Whether the plan is removing the prescription drug from the formulary, or changing its preferred or tiered, cost-sharing status; and
(C) The means by which subscribers may obtain a coverage determination or medical exception, in the case of drugs that will require prior authorization or are formulary exclusions respectively.
(ii) An accident and sickness insurer may immediately remove from its plan formularies covered prescription drugs deemed unsafe by the accident and sickness insurer or the Food and Drug Administration, or removed from the market by their manufacturer, without meeting the requirements of this section.
(e) 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; P.L. 2016, ch. 541, § 1.)