Nevada Revised Statutes 695C.1699 – Required provision concerning coverage for certain drugs and services related to substance use disorder and opioid use disorder; reimbursement of pharmacists and pharmacies for certain services; prohibited acts
1. A health maintenance organization that offers or issues a health care plan shall include in the plan coverage for:
Terms Used In Nevada Revised Statutes 695C.1699
- Contract: A legal written agreement that becomes binding when signed.
- Enrollee: means a natural person who has been voluntarily enrolled in a health care plan. See Nevada Revised Statutes 695C.030
- Health care plan: means any arrangement whereby any person undertakes to provide, arrange for, pay for or reimburse any part of the cost of any health care services and at least part of the arrangement consists of arranging for or the provision of health care services paid for by or on behalf of the enrollee on a periodic prepaid basis. See Nevada Revised Statutes 695C.030
- Health care services: means any services included in the furnishing to any natural person of medical or dental care or hospitalization or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any other services for the purpose of preventing, alleviating, curing or healing human illness or injury. See Nevada Revised Statutes 695C.030
- Health maintenance organization: means any person which provides or arranges for provision of a health care service or services and is responsible for the availability and accessibility of such service or services to its enrollees, which services are paid for or on behalf of the enrollees on a periodic prepaid basis without regard to the dates health services are rendered and without regard to the extent of services actually furnished to the enrollees, except that supplementing the fixed prepayments by nominal additional payments for services in accordance with regulations adopted by the Commissioner shall not be deemed to render the arrangement not to be on a prepaid basis. See Nevada Revised Statutes 695C.030
- physician: means a person who engages in the practice of medicine, including osteopathy and homeopathy. See Nevada Revised Statutes 0.040
- Provider: means any physician, hospital or other person who is licensed or otherwise authorized in this state to furnish health care services. See Nevada Revised Statutes 695C.030
(a) All drugs approved by the United States Food and Drug Administration to support safe withdrawal from substance use disorder, including, without limitation, lofexidine.
(b) All drugs approved by the United States Food and Drug Administration to provide medication-assisted treatment for opioid use disorder, including, without limitation, buprenorphine, methadone and naltrexone.
(c) The services described in NRS 639.28079 when provided by a pharmacist or pharmacy that participates in the network plan of the health maintenance organization. The Commissioner shall adopt regulations governing the provision of reimbursement for such services.
(d) Any service for the treatment of substance use disorder provided by a provider of primary care if the service is covered when provided by a specialist and:
(1) The service is within the scope of practice of the provider of primary care; or
(2) The provider of primary care is capable of providing the service safely and effectively in consultation with a specialist and the provider engages in such consultation.
2. A health maintenance organization that offers or issues a health care plan shall reimburse a pharmacist or pharmacy that participates in the network plan of the health maintenance organization for the services described in NRS 639.28079 at a rate equal to the rate of reimbursement provided to a physician, physician assistant or advanced practice registered nurse for similar services.
3. A health maintenance organization shall provide the coverage required by paragraphs (a) and (b) of subsection 1 regardless of whether the drug is included in the formulary of the health maintenance organization.
4. Except as otherwise provided in this subsection, a health maintenance organization shall not subject the benefits required by paragraphs (a), (b) and (c) of subsection 1 to medical management techniques, other than step therapy. A health maintenance organization may subject the benefits required by paragraphs (b) and (c) of subsection 1 to other reasonable medical management techniques when the benefits are provided by a pharmacist in accordance with NRS 639.28079.
5. A health maintenance organization shall not:
(a) Limit the covered amount of a drug described in paragraph (a) or (b) of subsection 1; or
(b) Refuse to cover a drug described in paragraph (a) or (b) of subsection 1 because the drug is dispensed by a pharmacy through mail order service.
6. A health maintenance organization shall ensure that the benefits required by subsection 1 are made available to an enrollee through a provider of health care who participates in the network plan of the health maintenance organization.
7. A health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by subsection 1, and any provision of the plan that conflicts with the provisions of this section is void.
8. As used in this section:
(a) ’Medical management technique’ means a practice which is used to control the cost or use of health care services or prescription drugs. The term includes, without limitation, the use of step therapy, prior authorization and categorizing drugs and devices based on cost, type or method of administration.
(b) ’Network plan’ means a health care plan offered by a health maintenance organization under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the health maintenance organization. The term does not include an arrangement for the financing of premiums.
(c) ’Primary care’ means the practice of family medicine, pediatrics, internal medicine, obstetrics and gynecology and midwifery.
(d) ’Provider of health care’ has the meaning ascribed to it in NRS 629.031.