P.R. Laws tit. 26, § 9050
(a) Each health insurance organization or issuer that uses a formulary or any other prescription drug management process shall, in the policy, certificate, membership booklet, outline of coverage, evidence of coverage, or any other document provided to a covered person or enrollee;
(1) Disclose the existence of the formulary and any other management processes and the fact that there may be other plan restrictions or requirements that may affect the specific prescription drugs that will be covered;
(2) describe the medical exception process that may be used to request coverage of nonformulary prescription drugs or to obtain an exception to dose restriction or step therapy requirements, and
(3) describe the process for filing a grievance, as set forth in the chapter on Health Insurance Organization or Issuer Grievance Procedure of this Code, to appeal a denial of a medical exception request.
(b) The policy, certificate, membership booklet, outline of coverage, evidence of coverage, or any other document provided to covered persons or enrollees shall explain, in layperson's terms, the information on the health insurance organization or issuer's formulary and each prescription drug management process. Such explanation shall also state that the health insurance organization or issuer shall provide covered persons or enrollees with a copy of the formulary and information about which prescription drugs are subject to a management process.
History —Aug. 29, 2011, No. 194, § 4.100, eff. 180 days after Aug. 29, 2011.