Coverage for prescription drugs: Provision of notice and information regarding use of formulary.
1. A prepaid limited health service organization that offers or issues evidence of coverage which provides coverage for prescription drugs shall include with any evidence of that coverage provided to a subscriber, notice of whether a formulary is used and, if so, of the opportunity to secure information regarding the formulary from the organization pursuant to subsection 2. The notice required by this subsection must:
(a) Be in a language that is easily understood and in a format that is easy to understand;
(b) Include an explanation of what a formulary is; and
(c) If a formulary is used, include:
(1) An explanation of:
(I) How often the contents of the formulary are reviewed; and
(II) The procedure and criteria for determining which prescription drugs are included in and excluded from the formulary; and
(2) The telephone number of the organization for making a request for information regarding the formulary pursuant to subsection 2.
2. If a prepaid limited health service organization offers or issues evidence of coverage which provides coverage for prescription drugs and a formulary is used, the organization shall:
(a) Provide to any enrollee or participating provider of health care, upon request:
(1) Information regarding whether a specific drug is included in the formulary.
(2) Access to the most current list of prescription drugs in the formulary, organized by major therapeutic category, with an indication of whether any listed drugs are preferred over other listed drugs. If more than one formulary is maintained, the organization shall notify the requester that a choice of formulary lists is available.
(b) Notify each person who requests information regarding the formulary, that the inclusion of a drug in the formulary does not guarantee that a provider of health care will prescribe that drug for a particular medical condition.
Last modified: February 27, 2006