Rhode Island General Laws 27-41-51. Drug coverage
(a) Any health maintenance organization that utilizes a formulary of medications for which coverage is provided under an individual or group plan master contract shall require any physician or other person authorized by the department of health to prescribe medication to prescribe from the formulary. A physician or other 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 non-formulary medication is medically necessary. A health maintenance organization 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.
Terms Used In Rhode Island General Laws 27-41-51
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Contract: A legal written agreement that becomes binding when signed.
- Health maintenance organization: means a single public or private organization that:
(i) Provides or makes available to enrolled participants healthcare services, including at least the following basic healthcare services: usual physician services, hospitalization, laboratory, x-ray, emergency, and preventive services, and out-of-area coverage, and the services of licensed midwives;
(ii) Is compensated, except for copayments, for the provision of the basic healthcare services listed in subsection (20)(i) of this section to enrolled participants on a predetermined periodic rate basis;
(iii)(A) Provides physicians' services primarily:
(I) Directly through physicians who are either employees or partners of the organization; or
(II) Through arrangements with individual physicians or one or more groups of physicians organized on a group practice or individual practice basis;
(B) "Health maintenance organization" does not include prepaid plans offered by entities regulated under chapter 1, 2, 19, or 20 of this title that do not meet the criteria above and do not purport to be health maintenance organizations; and
(iv) Provides the services of licensed midwives primarily:
(A) Directly through licensed midwives who are either employees or partners of the organization; or
(B) Through arrangements with individual licensed midwives or one or more groups of licensed midwives organized on a group practice or individual practice basis. See Rhode Island General Laws 27-41-2
- person: may be construed to extend to and include co-partnerships and bodies corporate and politic. See Rhode Island General Laws 43-3-6
- Physician: includes a podiatrist as defined in chapter 29 of Title 5. See Rhode Island General Laws 27-41-2
(b) A health maintenance organization’s medical-exception criteria for the coverage of non-formulary medications shall be developed in accordance with § 23-17.13-3(c)(3) [repealed].
(c) Any subscriber who is aggrieved by a denial of benefits to be provided under this section may appeal the denial in accordance with the rules and regulations promulgated by the department of health pursuant to chapter 17.12 of Title 23 [repealed].
(d) Prior to removing a prescription drug from its plan’s formulary or making any change in the preferred or tiered cost-sharing status of a covered prescription drug, a health maintenance organization must provide at least thirty (30) days’ notice to authorized prescribers by established communication methods of policy and program updates and by updating available references on web-based publications. All adversely affected members must be provided at least thirty (30) days’ notice prior to the date such change becomes effective by a direct notification:
(1) The written or electronic notice must contain the following information:
(i) The name of the affected prescription drug;
(ii) Whether the plan is removing the prescription drug from the formulary, or changing its preferred or tiered cost-sharing status; and
(iii) The means by which subscribers may obtain a coverage determination or medical exception, in the case of drugs that will require prior authorization or are formulary exclusions respectively.
(2) A health maintenance organization may immediately remove from its plan formularies covered prescription drugs deemed unsafe by the health maintenance organization or the Food and Drug Administration, or removed from the market by their manufacturer, without meeting the requirements of this section.
History of Section.
P.L. 1998, ch. 290, § 5; P.L. 2016, ch. 541, § 5; P.L. 2017, ch. 274, § 5; P.L. 2017, ch. 361, § 5.