26:2J-4.25 Health maintenance organization prescription drug plans to cover certain infant formulas.
6.A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of this act for a health maintenance organization that provides health care services for prescription drugs under a contract, unless the health maintenance organization also provides health care services in the purchase of specialized non-standard infant formulas, when the covered infant's physician has diagnosed the infant as having multiple food protein intolerance and has determined such formula to be medically necessary, and when the covered infant has not been responsive to trials of standard non-cow milk-based formulas, including soybean and goat milk. The coverage may be subject to utilization review, including periodic review, of the continued medical necessity of the specialized infant formula.
The health care services shall be provided to the same extent as for any other prescribed items under the contract.
The provisions of this section shall apply to those contracts for health care services by health maintenance organizations under which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage.
L.2001,c.361,s.6.
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Last modified: October 11, 2016