§ 27-41-51 - Drug coverage. - Rhode Island Statutes

SECTION 27-41-51

   § 27-41-51  Drug coverage. – (a) Any health maintenance organization 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 health maintenance organization's formulary if he or she believes that theprescription of non-formulary medication is medically necessary. A healthmaintenance organization shall be required to provide coverage for anon-formulary medication only when the non-formulary medication meets thehealth maintenance organization's medical exception criteria for the coverageof that medication.

   (b) A health maintenance organization's medical exceptioncriteria for the coverage of non-formulary medications shall be developed inaccordance 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.