RS 22:1060.3

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RS 22:1060.3

§1060.3. Continuation of coverage required; other drugs not precluded

A. A health insurance issuer of a health benefit plan that covers prescription drugs shall offer to each enrollee at the contracted benefit level and until the enrollee's plan renewal date any prescription drug that was approved or covered under the plan for a medical condition or medical illness, regardless of whether the drug has been removed from the health benefit plan's drug formulary before the plan renewal date. Nothing herein shall prohibit the health insurance issuer from providing information to the enrollee regarding alternative covered drugs.

B. This Section shall not prohibit a physician or other authorized prescriber from prescribing a drug that is an alternative to a drug for which continuation of coverage is required by Subsection A of this Section if the alternative drug meets each of the following conditions:

(1)The drug is covered under the health benefit plan.

(2)The drug is medically appropriate for the enrollee.

C.(1) A health insurance issuer proposing to change its coverage of a particular prescription drug or intravenous infusion based on medical necessity shall give notice of the proposed change to an insured currently using that prescription drug or intravenous infusion who the health insurance issuer determines the change may affect if the health insurance issuer has covered the drug or intravenous infusion for the insured for at least the preceding sixty days. Such notice shall be sent at least sixty days prior to the effective date of the proposed change.

(2)Any insured receiving such a notice from a health insurance issuer shall have the right to appeal the proposed change during the sixty-day notification period provided for in Paragraph

(1)of this Subsection in accordance with the Internal Claims and Appeals Process and External Review Act, R.S. 22:2391 et seq. In filing such an appeal, the insured shall document that his physician or authorized prescriber considers continued use of the drug or intravenous infusion to be medically necessary.

Acts 2011, No. 350, §1, eff. Jan. 1, 2012; Acts 2012, No. 316, §1, eff. May 25, 2012; Acts 2016, No. 573, §1, eff. Jan. 1, 2017.