62Q.527 NONFORMULARY ANTIPSYCHOTIC DRUGS; REQUIRED COVERAGE.

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Subdivision 1. Definitions.

(a)For purposes of this section, the following terms have the meanings given them.

(b)"Mental illness" has the meaning given in sections 245.462, subdivision 20 , paragraph (a), and 245.4871, subdivision 15 .

(c)"Health plan" has the meaning given in section 62Q.01, subdivision 3 , but includes the coverages described in section 62A.011, subdivision 3 , clauses

(7)and (10).

Subd. 2. Required coverage for antipsychotic drugs.

(a)A health plan that provides prescription drug coverage must provide coverage for an antipsychotic drug prescribed to treat mental illness regardless of whether the drug is in the health plan's drug formulary, if the health care provider prescribing the drug:

(1)indicates to the dispensing pharmacist, orally or in writing according to section 151.21 , that the prescription must be dispensed as communicated; and

(2)certifies in writing to the health plan company that the health care provider has considered all equivalent drugs in the health plan's drug formulary and has determined that the drug prescribed will best treat the patient's condition.

(b)The health plan is not required to provide coverage for a drug if the drug was removed from the health plan's drug formulary for safety reasons.

(c)For drugs covered under this section, no health plan company that has received a certification from the health care provider as described in paragraph

(a)may:

(1)impose a special deductible, co-payment, coinsurance, or other special payment requirement that the health plan does not apply to drugs that are in the health plan's drug formulary; or

(2)require written certification from the prescribing provider each time a prescription is refilled or renewed that the drug prescribed will best treat the patient's condition.

Subd. 3. Continuing care.

(a)Enrollees receiving a prescribed drug to treat a diagnosed mental illness may continue to receive the prescribed drug for up to one year without the imposition of a special deductible, co-payment, coinsurance, or other special payment requirements, when a health plan's drug formulary changes or an enrollee changes health plans and the medication has been shown to effectively treat the patient's condition. In order to be eligible for this continuing care benefit:

(1)the patient must have been treated with the drug for 90 days prior to a change in a health plan's drug formulary or a change in the enrollee's health plan;

(2)the health care provider prescribing the drug indicates to the dispensing pharmacist, orally or in writing according to section 151.21 , that the prescription must be dispensed as communicated; and

(3)the health care provider prescribing the drug certifies in writing to the health plan company that the drug prescribed will best treat the patient's condition.

(b)The continuing care benefit shall be extended annually when the health care provider prescribing the drug:

(1)indicates to the dispensing pharmacist, orally or in writing according to section 151.21 , that the prescription must be dispensed as communicated; and

(2)certifies in writing to the health plan company that the drug prescribed will best treat the patient's condition.

(c)The health plan company is not required to provide coverage for a drug if the drug was removed from the health plan's drug formulary for safety reasons.

Subd. 4. Exception to formulary.

A health plan company must promptly grant an exception to the health plan's drug formulary for an enrollee when the health care provider prescribing the drug indicates to the health plan company that:

(1)the formulary drug causes an adverse reaction in the patient;

(2)the formulary drug is contraindicated for the patient; or

(3)the health care provider demonstrates to the health plan that the prescription drug must be dispensed as written to provide maximum medical benefit to the patient.