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§27-19-42  Drug Coverage. –


Published: 2015

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TITLE 27

Insurance

CHAPTER 27-19

Nonprofit Hospital Service Corporations

SECTION 27-19-42



   § 27-19-42  Drug coverage. –

(a) Any nonprofit hospital service corporation 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 nonprofit hospital service corporation's formulary if he or she believes

that the prescription of the non-formulary medication is medically necessary. A

nonprofit hospital service corporation shall be required to provide coverage

for a non-formulary medication only when the non-formulary medication meets the

nonprofit hospital service corporation's medical exception criteria for the

coverage of that medication.



   (b) A nonprofit hospital service corporation'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.



History of Section.

(P.L. 1998, ch. 290, § 2.)