Introduced By: Representatives M. Anderson, Coderre, Kilmartin, Benoit, Garvey and McNamara
Date Introduced : February 3, 1998
It is enacted by the General Assembly as follows:
SECTION 1. Section 27-18 of the General Laws entitled "Accident and Sickness Insurance Policies" is hereby amended by adding thereto the following section:
{ADD 27-18-50. Drug Coverage. -- ADD} {ADD (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 provide that any physician or other person authorized by the department of health to prescribe medication, prescribe from the formulary. A physician or other such 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 such a 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. ADD}
{ADD (b) An accident and sickness insurer's medical exception criteria for the coverage of non-formulary medications shall be developed in accordance with section 23-17.13-3 (c) (3). ADD}
{ADD (c) Any subscriber who is aggrieved by a denial of benefits to be provided under this section may appeal said denial in accordance with the rules and regulations promulgated by the department of health pursuant to chapter 17.12 of title 23. ADD}
{ADD (d) Provided, however, this section shall not apply to insurance coverage providing benefits for: (i) hospital confinement indemnity; (ii) disability income; (iii) accident only; (iv) long term care; (v) medicare supplement; (vi) limited benefit health; (vii) specified disease indemnity; (viii) sickness or bodily injury or death by accident or both; or (ix) other limited benefit policies. ADD}
SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service Corporations" is hereby amended by adding thereto the following section:
{ADD 27-19-42. Drug Coverage. -- ADD} {ADD (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 provide that any physician or other person authorized by the department of health to prescribe medication, prescribe from the formulary. A physician or other such 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 such a 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. ADD}
{ADD (b) A nonprofit hospital service corporation's medical exception criteria for the coverage of non-formulary medications shall be developed in accordance with section 23-17.13-3 (c) (3). ADD}
{ADD (c) Any subscriber who is aggrieved by a denial of benefits to be provided under this section may appeal said denial in accordance with the rules and regulations promulgated by the department of health pursuant to chapter 17.12 of title 23. ADD}
SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service Corporations" is hereby amended by adding thereto the following section:
{ADD 27-20-37. Drug Coverage. -- ADD} {ADD (a) Any nonprofit medical service corporation that utilizes a formulary of medications for which coverage is provided under an individual or group plan master contract shall provide that any physician or other person authorized by the department of health to prescribe medication, prescribe from the formulary. A physician or other such person authorized by the department of health to prescribe medication shall be allowed to prescribe medications previously on, or not on, the nonprofit medical service corporation's formulary if he or she believes that the prescription of such a 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 medical service corporation's medical exception criteria for the coverage of that medication. ADD}
{ADD (b) A nonprofit medical service corporation's medical exception criteria for the coverage of non-formulary medications shall be developed in accordance with section 23-17.13-3 (c) (3). ADD}
{ADD (c) Any subscriber who is aggrieved by a denial of benefits to be provided under this section may appeal said denial in accordance with the rules and regulations promulgated by the department of health pursuant to chapter 17.12 of title 23. ADD}
SECTION 4. Chapter 27-20.1 of the General Laws entitled "Nonprofit Dental Service Corporations" is hereby amended by adding thereto the following section:
{ADD 27-20.1-15. Drug Coverage. -- ADD} {ADD (a) Any nonprofit dental service corporation that utilizes a formulary of medications for which coverage is provided under an individual or group plan master contract shall provide that any physician or other person authorized by the department of health to prescribe medication, prescribe from the formulary. A physician or other such person authorized by the department of health to prescribe medication shall be allowed to prescribe medications previously on, or not on, the nonprofit dental service corporation's formulary if he or she believes that the prescription of such a non-formulary medication is medically necessary. A nonprofit dental service corporation shall be required to provide coverage for a non-formulary medication only when the non-formulary medication meets the nonprofit dental service corporation's medical exception criteria for the coverage of that medication. ADD}
{ADD (b) A nonprofit dental service corporation's medical exception criteria for the coverage of non-formulary medications shall be developed in accordance with section 23-17.13-3 (c) (3). ADD}
{ADD (c) Any subscriber who is aggrieved by a denial of benefits to be provided under this section may appeal said denial in accordance with the rules and regulations promulgated by the department of health pursuant to chapter 17.12 of title 23. ADD}
SECTION 5. Chapter 27-41 of the General Laws entitled "Health Maintenance Organizations" is hereby amended by adding thereto the following section:
{ADD 27-41-51. Drug Coverage. -- ADD} {ADD (a) Any health maintenance organization's that utilizes a formulary of medications for which coverage is provided under an individual or group plan master contract shall provide that any physician or other person authorized by the department of health to prescribe medication, prescribe from the formulary. A physician or other such person authorized by the department of health to prescribe medication shall be allowed to prescribe medications previously on, or not on, the health maintenance organization's formulary if he or she believes that the prescription of such a non-formulary medication is medically necessary. A health maintenance organization's shall be required to provide coverage for a non-formulary medication only when the non-formulary medication meets the health maintenance organization's medical exception criteria for the coverage of that medication. ADD}
{ADD (b) A health maintenance organization's medical exception criteria for the coverage of non-formulary medications shall be developed in accordance with section 23-17.13-3 (c) (3). ADD}
{ADD (c) Any subscriber who is aggrieved by a denial of benefits to be provided under this section may appeal said denial in accordance with the rules and regulations promulgated by the department of health pursuant to chapter 17.12 of title 23. ADD}
SECTION 6. This act shall take effect on September 1, 1998.
