A health insurance issuer using drug formularies must give enrollees and requesters specific formulary notices and respond to formulary-status requests within 3 business days.
§1060.2. Notice and disclosure of certain information required A health insurance issuer of a health benefit plan that covers prescription drugs and uses one or more drug formularies to specify the prescription drugs covered under the plan shall do all of the following: (1) Provide in plain language in the coverage documentation provided to each enrollee each of the following: (a) Notice that the plan uses one or more drug formularies. (b) An explanation of what a drug formulary is. (c) A statement regarding the method the health insurance issuer uses to determine the prescription drugs to be included in or excluded from a drug formulary. (d) A statement of how often the health insurance issuer reviews the contents of each drug formulary. (e) Notice, on a form approved by the Department of Insurance, that an enrollee may contact the health insurance issuer to determine whether a specific drug is included in a particular drug formulary. (2) Disclose to an individual upon request, not later than the third business day after the date of the request, whether a specific drug is included in a particular drug formulary. (3) Notify an enrollee and any other individual who requests information pursuant to this Section that the inclusion of a drug in a drug formulary does not guarantee that an enrollee's physician or other authorized prescriber will prescribe the drug for a particular medical condition or mental illness. (4)(a) If a prescribed drug is denied based upon the drug's nonformulary status, provide the prescriber with a list of the alternative comparable formulary medications in writing and attached to the letter of denial of prescription drug coverage. (b) If a prescribed drug is excluded from coverage under the health benefit plan and other drugs in the same class and used for the same treatment as the excluded drug are covered under the plan, the issuer or its agent shall notify the prescriber of the covered drug. (c) It shall be deemed sufficient to meet the requirements of this Paragraph if a health benefit plan includes the information required by this Paragraph in the denial letter sent by the health benefit plan or its agent. For any request made by providers utilizing electronic health records with capabilities, the notice may be sent electronically. (d) Simple notification of the availability and location of the formulary shall not be deemed sufficient to meet the requirements of this Paragraph. Acts 2011, No. 350, §1, eff. Jan. 1, 2012; Acts 2019, No. 206, §1, eff. Jan. 1, 2020.