§ 27-19-42 - Drug coverage.
SECTION 27-19-42
§ 27-19-42 Drug coverage. – (a) Any nonprofit hospital service corporation that utilizes a formulary ofmedications for which coverage is provided under an individual or group planmaster contract shall require any physician or other person authorized by thedepartment of health to prescribe medication to prescribe from the formulary. Aphysician or other person authorized by the department of health to prescribemedication shall be allowed to prescribe medications previously on, or not on,the nonprofit hospital service corporation's formulary if he or she believesthat the prescription of the non-formulary medication is medically necessary. Anonprofit hospital service corporation shall be required to provide coveragefor a non-formulary medication only when the non-formulary medication meets thenonprofit hospital service corporation's medical exception criteria for thecoverage of that medication.
(b) A nonprofit hospital service corporation's medicalexception criteria for the coverage of non-formulary medications shall bedeveloped in accordance with § 23-17.13-3(c)(3).
(c) Any subscriber who is aggrieved by a denial of benefitsto be provided under this section may appeal the denial in accordance with therules and regulations promulgated by the department of health pursuant tochapter 17.12 of title 23.