La. Admin. Code tit. 37 § XIII-14111

Current through Register Vol. 50, No. 9, September 20, 2024

Section XIII-14111 - Requirements for the Modification Affecting Drug Coverage

A. A modification affecting drug coverage shall mean any of the following:

1. removing a drug from a formulary;

2. adding a requirement that an enrollee receive prior authorization for a drug;

3. imposing or altering a quantity limit for a drug;

4. imposing a step-therapy restriction for a drug;

5. moving a drug to a higher cost-sharing tier, unless a generic alternative is available.

B. A health insurance issuer shall notify the commissioner in writing of a modification affecting drug coverage 75 days prior to the renewal date of the policy form as to those modifications enumerated in R.S. 22:1061(5) and set forth in § 14111.A herein. A health insurance issuer shall provide the notice of modification affecting drug coverage as provided for in R.S. 22:1068(D)(3) and R.S. 22:1074(D)(3) and shall only modify the policy or contract of insurance at the renewal of the policy or contract of insurance.

C. A modification of drug coverage for any drug increasing over $300 per prescription or refill with an increase in the wholesale acquisition cost of at least 25% in the prior 365 days may occur at any time provided that 30-day notice of the modification of coverage is given. The 30-day notice of the modification of coverage shall include information on the health insurance issuer's process for an enrollee's physician to request an exception from the health insurance issuer's modification of drug coverage for purposes of continuity of care of the patient.

La. Admin. Code tit. 37, § XIII-14111

Promulgated by the Department of Insurance, Office of the Commissioner, LR 38:1028 (April 2012), Amended LR 451207 (9/1/2019), Repromulgated LR 451778 (12/1/2019), Amended LR 482298 (9/1/2022).

AUTHORITY NOTE: Promulgated in accordance with R.S.22:11, R.S. 1068(D) and R.S. 22:1074(D).