Senate Bill No. 2–Senator Amodei
Prefiled January 11, 2001
____________
Referred to Committee on Commerce and Labor
SUMMARY—Requires provider of insurance coverage for
prescription drugs to disclose certain information regarding use of formulary
and to continue coverage for prescribed drug under certain circumstances. (BDR 57‑597)
FISCAL NOTE: Effect on Local Government: No.
~
EXPLANATION
– Matter in bolded italics is new; matter
between brackets [omitted material] is material to be omitted.
Green numbers along
left margin indicate location on the printed bill (e.g., 5-15 indicates page 5, line 15).
AN ACT relating to insurance; requiring a provider of coverage for prescription drugs to
disclose certain information regarding the use of a formulary; prohibiting such
a provider from limiting or excluding coverage for a prescribed drug under
certain circumstances; and providing other matters properly relating thereto.
THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN
SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:
1-1 Section
1. Chapter 689A of NRS is
hereby amended by adding
1-2 thereto the provisions set forth as sections 2 and 3
of this act.
1-3 Sec. 2. 1. An insurer that offers or issues a policy of health
1-4 insurance which
provides coverage for prescription drugs shall include
1-5 with any summary,
certificate or evidence of that coverage provided to an
1-6 insured, notice
of whether a formulary is used and, if so, of the
1-7 opportunity to
secure information regarding the formulary from the
1-8 insurer pursuant
to subsection 2. The notice required by this subsection
1-9 must:
1-10 (a) Be in a language that is easily understood
and in a format that is
1-11 easy to
understand;
1-12 (b) Include an explanation of what a formulary
is; and
1-13 (c) If a formulary is used, include:
1-14 (1) An explanation of:
1-15 (I) How often the contents of the
formulary are reviewed; and
1-16 (II) The procedure and criteria for
determining which
1-17 prescription
drugs are included in and excluded from the formulary; and
2-1 (2) The telephone number of the insurer for
making a request for
2-2 information
regarding the formulary pursuant to subsection 2.
2-3 2. If
an insurer offers or issues a policy of health insurance which
2-4 provides coverage
for prescription drugs and a formulary is used, the
2-5 insurer shall:
2-6 (a) Provide to any person, upon request:
2-7 (1) Information regarding whether a
specific drug is included in the
2-8 formulary.
2-9 (2) A copy of the most current list of
prescription drugs in the
2-10 formulary,
organized by major therapeutic category, with an indication
2-11 of whether any
listed drugs are preferred over other listed drugs. If more
2-12 than one
formulary is maintained, the insurer shall notify the requester
2-13 that a choice of
formulary lists is available.
2-14 (b) Notify each person who requests
information regarding the
2-15 formulary, that
the inclusion of a drug in the formulary does not
2-16 guarantee that a
provider of health care will prescribe that drug for a
2-17 particular
medical condition.
2-18 Sec. 3. 1. Except as otherwise provided in this section, a policy of
2-19 health insurance
which provides coverage for prescription drugs must
2-20 not limit or
exclude coverage for a drug if the drug:
2-21 (a) Had previously been approved for coverage
by the insurer for a
2-22 medical condition
of an insured and the insured’s provider of health care
2-23 continues to
prescribe the drug for the medical condition; and
2-24 (b) Is appropriately prescribed and considered
safe and effective for
2-25 treating the
medical condition of the insured.
2-26 2. The
provisions of subsection 1 do not:
2-27 (a) Apply to coverage for any drug that is
prescribed for a use that is
2-28 different from
the use for which that drug has been approved for
2-29 marketing by the
Food and Drug Administration; or
2-30 (b) Prohibit:
2-31 (1) The insurer from charging a deductible,
copayment or
2-32 coinsurance for
the provision of benefits for prescription drugs to the
2-33 insured or from
establishing, by contract, limitations on the maximum
2-34 coverage for
prescription drugs;
2-35 (2) A provider of health care from
prescribing another drug covered
2-36 by the policy
that is medically appropriate for the insured; or
2-37 (3) The substitution of another drug
pursuant to NRS 639.23286 or
2-38 639.2583 to
639.2599, inclusive.
2-39 3. Any
provision of a policy subject to the provisions of this chapter
2-40 that is
delivered, issued for delivery or renewed on or after October 1,
2-41 2001, which is in
conflict with this section is void.
2-42 Sec. 4. Chapter
689B of NRS is hereby amended by adding thereto
2-43 the provisions set forth as sections 5 and 6 of this
act.
2-44 Sec. 5. 1. An insurer that offers or issues a policy of group health
2-45 insurance which
provides coverage for prescription drugs shall include
2-46 with any summary,
certificate or evidence of that coverage provided to an
2-47 insured, notice
of whether a formulary is used and, if so, of the
2-48 opportunity to secure
information regarding the formulary from the
3-1 insurer pursuant
to subsection 2. The notice required by this subsection
3-2 must:
3-3 (a) Be in a language that is easily understood
and in a format that is
3-4 easy to
understand;
3-5 (b) Include an explanation of what a formulary
is; and
3-6 (c) If a formulary is used, include:
3-7 (1) An explanation of:
3-8 (I) How often the contents of the
formulary are reviewed; and
3-9 (II) The procedure and criteria for
determining which
3-10 prescription
drugs are included in and excluded from the formulary; and
3-11 (2) The telephone number of the insurer for
making a request for
3-12 information
regarding the formulary pursuant to subsection 2.
3-13 2. If
an insurer offers or issues a policy of group health insurance
3-14 which provides
coverage for prescription drugs and a formulary is used,
3-15 the insurer
shall:
3-16 (a) Provide to any person, upon request:
3-17 (1) Information regarding whether a specific
drug is included in the
3-18 formulary.
3-19 (2) A copy of the most current list of
prescription drugs in the
3-20 formulary,
organized by major therapeutic category, with an indication
3-21 of whether any
listed drugs are preferred over other listed drugs. If more
3-22 than one
formulary is maintained, the insurer shall notify the requester
3-23 that a choice of
formulary lists is available.
3-24 (b) Notify each person who requests
information regarding the
3-25 formulary, that
the inclusion of a drug in the formulary does not
3-26 guarantee that a
provider of health care will prescribe that drug for a
3-27 particular
medical condition.
3-28 Sec. 6. 1. Except as otherwise provided in this section, a policy of
3-29 group health
insurance which provides coverage for prescription drugs
3-30 must not limit or
exclude coverage for a drug if the drug:
3-31 (a) Had previously been approved for coverage
by the insurer for a
3-32 medical condition
of an insured and the insured’s provider of health care
3-33 continues to
prescribe the drug for the medical condition; and
3-34 (b) Is appropriately prescribed and considered
safe and effective for
3-35 treating the
medical condition of the insured.
3-36 2. The
provisions of subsection 1 do not:
3-37 (a) Apply to coverage for any drug that is
prescribed for a use that is
3-38 different from
the use for which that drug has been approved for
3-39 marketing by the
Food and Drug Administration; or
3-40 (b) Prohibit:
3-41 (1) The insurer from charging a deductible,
copayment or
3-42 coinsurance for
the provision of benefits for prescription drugs to the
3-43 insured or from
establishing, by contract, limitations on the maximum
3-44 coverage for
prescription drugs;
3-45 (2) A provider of health care from
prescribing another drug covered
3-46 by the policy
that is medically appropriate for the insured; or
3-47 (3) The substitution of another drug
pursuant to NRS 639.23286 or
3-48 639.2583 to
639.2599, inclusive.
4-1 3. Any
provision of a policy subject to the provisions of this chapter
4-2 that is
delivered, issued for delivery or renewed on or after October 1,
4-3 2001, which is in
conflict with this section is void.
4-4 Sec. 7. Chapter
689C of NRS is hereby amended by adding thereto
4-5 the provisions set forth as sections 8, 9 and 10 of
this act.
4-6 Sec. 8. 1. A carrier that offers or issues a health benefit plan
4-7 which provides
coverage for prescription drugs shall include with any
4-8 summary,
certificate or evidence of that coverage provided to an insured,
4-9 notice of whether
a formulary is used and, if so, of the opportunity to
4-10 secure information
regarding the formulary from the carrier pursuant to
4-11 subsection 2. The
notice required by this subsection must:
4-12 (a) Be in a language that is easily understood
and in a format that is
4-13 easy to
understand;
4-14 (b) Include an explanation of what a formulary
is; and
4-15 (c) If a formulary is used, include:
4-16 (1) An explanation of:
4-17 (I) How often the contents of the
formulary are reviewed; and
4-18 (II) The procedure and criteria for
determining which
4-19 prescription
drugs are included in and excluded from the formulary; and
4-20 (2) The telephone number of the carrier for
making a request for
4-21 information
regarding the formulary pursuant to subsection 2.
4-22 2. If
a carrier offers or issues a health benefit plan which provides
4-23 coverage for
prescription drugs and a formulary is used, the carrier
4-24 shall:
4-25 (a) Provide to any person, upon request:
4-26 (1) Information regarding whether a specific
drug is included in the
4-27 formulary.
4-28 (2) A copy of the most current list of
prescription drugs in the
4-29 formulary,
organized by major therapeutic category, with an indication
4-30 of whether any
listed drugs are preferred over other listed drugs. If more
4-31 than one
formulary is maintained, the carrier shall notify the requester
4-32 that a choice of
formulary lists is available.
4-33 (b) Notify each person who requests
information regarding the
4-34 formulary, that
the inclusion of a drug in the formulary does not
4-35 guarantee that a
provider of health care will prescribe that drug for a
4-36 particular
medical condition.
4-37 Sec. 9. 1. Except as otherwise provided in this section, a health
4-38 benefit plan
which provides coverage for prescription drugs must not
4-39 limit or exclude
coverage for a drug if the drug:
4-40 (a) Had previously been approved for coverage
by the carrier for a
4-41 medical condition
of an insured and the insured’s provider of health care
4-42 continues to
prescribe the drug for the medical condition; and
4-43 (b) Is appropriately prescribed and considered
safe and effective for
4-44 treating the
medical condition of the insured.
4-45 2. The
provisions of subsection 1 do not:
4-46 (a) Apply to coverage for any drug that is
prescribed for a use that is
4-47 different from
the use for which that drug has been approved for
4-48 marketing by the
Food and Drug Administration; or
4-49 (b) Prohibit:
5-1 (1) The carrier from charging a deductible,
copayment or
5-2 coinsurance for
the provision of benefits for prescription drugs to the
5-3 insured or from
establishing, by contract, limitations on the maximum
5-4 coverage for
prescription drugs;
5-5 (2) A provider of health care from
prescribing another drug covered
5-6 by the plan that
is medically appropriate for the insured; or
5-7 (3) The substitution of another drug pursuant
to NRS 639.23286 or
5-8 639.2583 to
639.2599, inclusive.
5-9 3. Any
provision of a health benefit plan subject to the provisions of
5-10 this chapter that
is delivered, issued for delivery or renewed on or after
5-11 October 1, 2001,
which is in conflict with this section is void.
5-12 Sec. 10. 1. A carrier that offers or issues a contract which provides
5-13 coverage for
prescription drugs shall include with any summary,
5-14 certificate or
evidence of that coverage provided to an insured, notice of
5-15 whether a
formulary is used and, if so, of the opportunity to secure
5-16 information
regarding the formulary from the carrier pursuant to
5-17 subsection 2. The
notice required by this subsection must:
5-18 (a) Be in a language that is easily understood
and in a format that is
5-19 easy to
understand;
5-20 (b) Include an explanation of what a formulary
is; and
5-21 (c) If a formulary is used, include:
5-22 (1) An explanation of:
5-23 (I) How often the contents of the
formulary are reviewed; and
5-24 (II) The procedure and criteria for
determining which
5-25 prescription
drugs are included in and excluded from the formulary; and
5-26 (2) The telephone number of the carrier for
making a request for
5-27 information
regarding the formulary pursuant to subsection 2.
5-28 2. If
a carrier offers or issues a contract which provides coverage for
5-29 prescription
drugs and a formulary is used, the carrier shall:
5-30 (a) Provide to any person, upon request:
5-31 (1) Information regarding whether a specific
drug is included in the
5-32 formulary.
5-33 (2) A copy of the most current list of
prescription drugs in the
5-34 formulary,
organized by major therapeutic category, with an indication
5-35 of whether any
listed drugs are preferred over other listed drugs. If more
5-36 than one
formulary is maintained, the carrier shall notify the requester
5-37 that a choice of
formulary lists is available.
5-38 (b) Notify each person who requests information
regarding the
5-39 formulary, that
the inclusion of a drug in the formulary does not
5-40 guarantee that a
provider of health care will prescribe that drug for a
5-41 particular
medical condition.
5-42 Sec. 11. NRS
689C.425 is hereby amended to read as follows:
5-43 689C.425 A voluntary purchasing group and any contract
issued to
5-44 such a group pursuant to NRS 689C.360 to 689C.600,
inclusive, and
5-45 section 10 of
this act are
subject to the provisions of NRS 689C.015 to
5-46 689C.355, inclusive, and sections 8 and 9 of this act to the extent
5-47 applicable and not in conflict with the express
provisions of NRS 689C.360
5-48 to 689C.600, inclusive, and [this section.] section 10 of this act.
6-1 Sec. 12. Chapter
695A of NRS is hereby amended by adding thereto
6-2 the provisions set forth as sections 13 and 14 of
this act.
6-3 Sec. 13. 1. A society that offers or issues a benefit contract which
6-4 provides coverage
for prescription drugs shall include with any
6-5 certificate for
such a contract provided to a benefit member, notice of
6-6 whether a
formulary is used and, if so, of the opportunity to secure
6-7 information
regarding the formulary from the society pursuant to
6-8 subsection 2. The
notice required by this subsection must:
6-9 (a) Be in a language that is easily understood
and in a format that is
6-10 easy to
understand;
6-11 (b) Include an explanation of what a formulary
is; and
6-12 (c) If a formulary is used, include:
6-13 (1) An explanation of:
6-14 (I) How often the contents of the
formulary are reviewed; and
6-15 (II) The procedure and criteria for
determining which
6-16 prescription
drugs are included in and excluded from the formulary; and
6-17 (2) The telephone number of the society for
making a request for
6-18 information
regarding the formulary pursuant to subsection 2.
6-19 2. If
a society offers or issues a benefit contract which provides
6-20 coverage for
prescription drugs and a formulary is used, the society
6-21 shall:
6-22 (a) Provide to any person, upon request:
6-23 (1) Information regarding whether a specific
drug is included in the
6-24 formulary.
6-25 (2) A copy of the most current list of
prescription drugs in the
6-26 formulary,
organized by major therapeutic category, with an indication
6-27 of whether any
listed drugs are preferred over other listed drugs. If more
6-28 than one
formulary is maintained, the society shall notify the requester
6-29 that a choice of
formulary lists is available.
6-30 (b) Notify each person who requests
information regarding the
6-31 formulary, that
the inclusion of a drug in the formulary does not
6-32 guarantee that a
provider of health care will prescribe that drug for a
6-33 particular
medical condition.
6-34 Sec. 14. 1. Except as otherwise provided in this section, a benefit
6-35 contract which
provides coverage for prescription drugs must not limit or
6-36 exclude coverage
for a drug if the drug:
6-37 (a) Had previously been approved for coverage
by the society for a
6-38 medical condition
of an insured and the insured’s provider of health care
6-39 continues to
prescribe the drug for the medical condition; and
6-40 (b) Is appropriately prescribed and considered
safe and effective for
6-41 treating the medical
condition of the insured.
6-42 2. The
provisions of subsection 1 do not:
6-43 (a) Apply to coverage for any drug that is
prescribed for a use that is
6-44 different from
the use for which that drug has been approved for
6-45 marketing by the
Food and Drug Administration; or
6-46 (b) Prohibit:
6-47 (1) The society from charging a deductible,
copayment or
6-48 coinsurance for
the provision of benefits for prescription drugs to the
7-1 insured or from
establishing, by contract, limitations on the maximum
7-2 coverage for
prescription drugs;
7-3 (2) A provider of health care from
prescribing another drug covered
7-4 by the benefit
contract that is medically appropriate for the insured; or
7-5 (3) The substitution of another drug
pursuant to NRS 639.23286 or
7-6 639.2583 to
639.2599, inclusive.
7-7 3. Any
provision of a benefit contract subject to the provisions of this
7-8 chapter that is
delivered, issued for delivery or renewed on or after
7-9 October 1, 2001,
which is in conflict with this section is void.
7-10 Sec. 15. Chapter
695B of NRS is hereby amended by adding thereto
7-11 the provisions set forth as sections 16 and 17 of
this act.
7-12 Sec. 16. 1. An insurer that offers or issues a contract for hospital
7-13 or medical
services which provides coverage for prescription drugs shall
7-14 include with any
summary, certificate or evidence of that coverage
7-15 provided to an
insured, notice of whether a formulary is used and, if so,
7-16 of the opportunity
to secure information regarding the formulary from
7-17 the insurer
pursuant to subsection 2. The notice required by this
7-18 subsection must:
7-19 (a) Be in a language that is easily understood
and in a format that is
7-20 easy to
understand;
7-21 (b) Include an explanation of what a formulary
is; and
7-22 (c) If a formulary is used, include:
7-23 (1) An explanation of:
7-24 (I) How often the contents of the
formulary are reviewed; and
7-25 (II) The procedure and criteria for
determining which
7-26 prescription
drugs are included in and excluded from the formulary; and
7-27 (2) The telephone number of the insurer for
making a request for
7-28 information
regarding the formulary pursuant to subsection 2.
7-29 2. If
an insurer offers or issues a contract for hospital or medical
7-30 services which
provides coverage for prescription drugs and a formulary
7-31 is used, the
insurer shall:
7-32 (a) Provide to any person, upon request:
7-33 (1) Information regarding whether a specific
drug is included in the
7-34 formulary.
7-35 (2) A copy of the most current list of
prescription drugs in the
7-36 formulary,
organized by major therapeutic category, with an indication
7-37 of whether any
listed drugs are preferred over other listed drugs. If more
7-38 than one
formulary is maintained, the insurer shall notify the requester
7-39 that a choice of
formulary lists is available.
7-40 (b) Notify each person who requests
information regarding the
7-41 formulary, that
the inclusion of a drug in the formulary does not
7-42 guarantee that a
provider of health care will prescribe that drug for a
7-43 particular
medical condition.
7-44 Sec. 17. 1. Except as otherwise provided in this section, a contract
7-45 for hospital or
medical services which provides coverage for prescription
7-46 drugs must not
limit or exclude coverage for a drug if the drug:
7-47 (a) Had previously been approved for coverage
by the insurer for a
7-48 medical condition
of an insured and the insured’s provider of health care
7-49 continues to
prescribe the drug for the medical condition; and
8-1 (b) Is appropriately prescribed and considered
safe and effective for
8-2 treating the
medical condition of the insured.
8-3 2. The
provisions of subsection 1 do not:
8-4 (a) Apply to coverage for any drug that is
prescribed for a use that is
8-5 different from
the use for which that drug has been approved for
8-6 marketing by the
Food and Drug Administration; or
8-7 (b) Prohibit:
8-8 (1) The insurer from charging a deductible,
copayment or
8-9 coinsurance for
the provision of benefits for prescription drugs to the
8-10 insured or from
establishing, by contract, limitations on the maximum
8-11 coverage for
prescription drugs;
8-12 (2) A provider of health care from
prescribing another drug covered
8-13 by the contract
that is medically appropriate for the insured; or
8-14 (3) The substitution of another drug
pursuant to NRS 639.23286 or
8-15 639.2583 to
639.2599, inclusive.
8-16 3. Any
provision of a contract for hospital or medical services subject
8-17 to the provisions
of this chapter that is delivered, issued for delivery or
8-18 renewed on or
after October 1, 2001, which is in conflict with this section
8-19 is void.
8-20 Sec. 18. Chapter
695C of NRS is hereby amended by adding thereto
8-21 the provisions set forth as sections 19 and 20 of
this act.
8-22 Sec. 19. 1. A health maintenance organization or insurer that
8-23 offers or issues
evidence of coverage which provides coverage for
8-24 prescription
drugs shall include with any evidence of that coverage
8-25 provided to an
enrollee, notice of whether a formulary is used and, if so,
8-26 of the
opportunity to secure information regarding the formulary from
8-27 the organization
or insurer pursuant to subsection 2. The notice required
8-28 by this
subsection must:
8-29 (a) Be in a language that is easily understood
and in a format that is
8-30 easy to
understand;
8-31 (b) Include an explanation of what a formulary
is; and
8-32 (c) If a formulary is used, include:
8-33 (1) An explanation of:
8-34 (I) How often the contents of the formulary
are reviewed; and
8-35 (II) The procedure and criteria for
determining which
8-36 prescription
drugs are included in and excluded from the formulary; and
8-37 (2) The telephone number of the organization
or insurer for
8-38 making a request
for information regarding the formulary pursuant to
8-39 subsection 2.
8-40 2. If
a health maintenance organization or insurer offers or issues
8-41 evidence of
coverage which provides coverage for prescription drugs and
8-42 a formulary is
used, the organization or insurer shall:
8-43 (a) Provide to any person, upon request:
8-44 (1) Information regarding whether a specific
drug is included in the
8-45 formulary.
8-46 (2) A copy of the most current list of
prescription drugs in the
8-47 formulary,
organized by major therapeutic category, with an indication
8-48 of whether any
listed drugs are preferred over other listed drugs. If more
9-1 than one
formulary is maintained, the organization or insurer shall
9-2 notify the
requester that a choice of formulary lists is available.
9-3 (b) Notify each person who requests
information regarding the
9-4 formulary, that
the inclusion of a drug in the formulary does not
9-5 guarantee that a
provider of health care will prescribe that drug for a
9-6 particular
medical condition.
9-7 Sec. 20. 1. Except as otherwise provided in this section, evidence
9-8 of coverage which
provides coverage for prescription drugs must not
9-9 limit or exclude
coverage for a drug if the drug:
9-10 (a) Had previously been approved for coverage
by the health
9-11 maintenance
organization or insurer for a medical condition of an
9-12 enrollee and the
enrollee’s provider of health care continues to prescribe
9-13 the drug for the
medical condition; and
9-14 (b) Is appropriately prescribed and considered
safe and effective for
9-15 treating the
medical condition of the enrollee.
9-16 2. The
provisions of subsection 1 do not:
9-17 (a) Apply to coverage for any drug that is
prescribed for a use that is
9-18 different from
the use for which that drug has been approved for
9-19 marketing by the
Food and Drug Administration; or
9-20 (b) Prohibit:
9-21 (1) The health maintenance organization or
insurer from charging
9-22 a deductible,
copayment or coinsurance for the provision of benefits for
9-23 prescription
drugs to the enrollee or from establishing, by contract,
9-24 limitations on
the maximum coverage for prescription drugs;
9-25 (2) A provider of health care from
prescribing another drug covered
9-26 by the evidence
of coverage that is medically appropriate for the enrollee;
9-27 or
9-28 (3) The substitution of another drug
pursuant to NRS 639.23286 or
9-29 639.2583 to
639.2599, inclusive.
9-30 3. Any
provision of an evidence of coverage subject to the provisions
9-31 of this chapter
that is delivered, issued for delivery or renewed on or after
9-32 October 1, 2001,
which is in conflict with this section is void.
9-33 Sec. 21. NRS
695C.050 is hereby amended to read as follows:
9-34 695C.050 1. Except
as otherwise provided in this chapter or in
9-35 specific provisions of this Title, the provisions of
this Title are not
9-36 applicable to any health maintenance organization
granted a certificate of
9-37 authority under this chapter. This provision does not
apply to an insurer
9-38 licensed and regulated pursuant to this Title except
with respect to its
9-39 activities as a health maintenance organization
authorized and regulated
9-40 pursuant to this chapter.
9-41 2. Solicitation of enrollees by a health
maintenance organization
9-42 granted a certificate of authority, or its
representatives, must not be
9-43 construed to violate any provision of law relating
to solicitation or
9-44 advertising by practitioners of a healing art.
9-45 3. Any health maintenance organization
authorized under this chapter
9-46 shall not be deemed to be practicing medicine and is
exempt from the
9-47 provisions of chapter 630 of NRS.
9-48 4. The provisions of NRS 695C.110, 695C.170 to
695C.200, inclusive,
9-49 and sections 19
and 20 of this act, NRS 695C.250 and 695C.265 do not
10-1 apply to a health maintenance organization that
provides health care
10-2 services through managed care to recipients of
Medicaid under the state
10-3 plan for Medicaid or insurance pursuant to the
children’s health insurance
10-4 program pursuant to a contract with the division of
health care financing
10-5 and policy of the department of human resources.
This subsection does not
10-6 exempt a health maintenance organization from any
provision of this
10-7 chapter for services provided pursuant to any other
contract.
10-8 5. The provisions of NRS 695C.1694
and 695C.1695
apply to a health
10-9 maintenance organization that provides health care
services through
10-10 managed care to recipients of Medicaid under the
state plan for Medicaid.
10-11 Sec. 22. Chapter
695F of NRS is hereby amended by adding thereto
10-12 the provisions set forth as sections 23 and 24 of
this act.
10-13 Sec. 23. 1. A prepaid limited health service organization that offers
10-14 or issues
evidence of coverage which provides coverage for prescription
10-15 drugs shall
include with any evidence of that coverage provided to a
10-16 subscriber,
notice of whether a formulary is used and, if so, of the
10-17 opportunity to
secure information regarding the formulary from the
10-18 organization
pursuant to subsection 2. The notice required by this
10-19 subsection must:
10-20 (a) Be in a language that is easily understood
and in a format that is
10-21 easy to
understand;
10-22 (b) Include an explanation of what a formulary
is; and
10-23 (c) If a formulary is used, include:
10-24 (1) An explanation of:
10-25 (I) How often the contents of the formulary
are reviewed; and
10-26 (II) The procedure and criteria for
determining which
10-27 prescription
drugs are included in and excluded from the formulary; and
10-28 (2) The telephone number of the organization
for making a request
10-29 for information
regarding the formulary pursuant to subsection 2.
10-30 2. If a
prepaid limited health service organization offers or issues
10-31 evidence of
coverage which provides coverage for prescription drugs and
10-32 a formulary is
used, the organization shall:
10-33 (a) Provide to any person, upon request:
10-34 (1) Information regarding whether a specific
drug is included in the
10-35 formulary.
10-36 (2) A copy of the most current list of
prescription drugs in the
10-37 formulary,
organized by major therapeutic category, with an indication
10-38 of whether any
listed drugs are preferred over other listed drugs. If more
10-39 than one
formulary is maintained, the organization shall notify the
10-40 requester that a
choice of formulary lists is available.
10-41 (b) Notify each person who requests information
regarding the
10-42 formulary, that
the inclusion of a drug in the formulary does not
10-43 guarantee that a
provider of health care will prescribe that drug for a
10-44 particular
medical condition.
10-45 Sec. 24. 1. Except as otherwise provided in this section, evidence
10-46 of coverage which
provides coverage for prescription drugs must not
10-47 limit or exclude
coverage for a drug if the drug:
10-48 (a) Had previously been approved for coverage
by the prepaid limited
10-49 health service
organization for a medical condition of an enrollee and
11-1 the enrollee’s
provider of health care continues to prescribe the drug for
11-2 the medical
condition; and
11-3 (b) Is appropriately prescribed and considered
safe and effective for
11-4 treating the
medical condition of the enrollee.
11-5 2. The
provisions of subsection 1 do not:
11-6 (a) Apply to coverage for any drug that is
prescribed for a use that is
11-7 different from
the use for which that drug has been approved for
11-8 marketing by the
Food and Drug Administration; or
11-9 (b) Prohibit:
11-10 (1) The organization from charging a
deductible, copayment or
11-11 coinsurance for
the provision of benefits for prescription drugs to the
11-12 enrollee or from
establishing, by contract, limitations on the maximum
11-13 coverage for
prescription drugs;
11-14 (2) A provider of health care from
prescribing another drug covered
11-15 by the evidence
of coverage that is medically appropriate for the enrollee;
11-16 or
11-17 (3) The substitution of another drug pursuant
to NRS 639.23286 or
11-18 639.2583 to
639.2599, inclusive.
11-19 3. Any
provision of an evidence of coverage subject to the provisions
11-20 of this chapter
that is delivered, issued for delivery or renewed on or after
11-21 October 1, 2001,
which is in conflict with this section is void.
11-22 Sec. 25. Chapter
695G of NRS is hereby amended by adding thereto
11-23 the provisions set forth as sections 26 and 27 of
this act.
11-24 Sec. 26. 1. A managed care organization that offers or issues a
11-25 health care plan
which provides coverage for prescription drugs shall
11-26 include with any
summary, certificate or evidence of that coverage
11-27 provided to an
insured, notice of whether a formulary is used and, if so,
11-28 of the
opportunity to secure information regarding the formulary from
11-29 the organization
pursuant to subsection 2. The notice required by this
11-30 subsection must:
11-31 (a) Be in a language that is easily understood
and in a format that is
11-32 easy to
understand;
11-33 (b) Include an explanation of what a formulary
is; and
11-34 (c) If a formulary is used, include:
11-35 (1) An explanation of:
11-36 (I) How often the contents of the formulary
are reviewed; and
11-37 (II) The procedure and criteria for
determining which
11-38 prescription
drugs are included in and excluded from the formulary; and
11-39 (2) The telephone number of the organization
for making a request
11-40 for information
regarding the formulary pursuant to subsection 2.
11-41 2. If a
managed care organization offers or issues a health care plan
11-42 which provides
coverage for prescription drugs and a formulary is used,
11-43 the organization
shall:
11-44 (a) Provide to any person, upon request:
11-45 (1) Information regarding whether a specific
drug is included in the
11-46 formulary.
11-47 (2) A copy of the most current list of
prescription drugs in the
11-48 formulary,
organized by major therapeutic category, with an indication
11-49 of whether any
listed drugs are preferred over other listed drugs. If more
12-1 than one
formulary is maintained, the organization shall notify the
12-2 requester that a
choice of formulary lists is available.
12-3 (b) Notify each person who requests
information regarding the
12-4 formulary, that
the inclusion of a drug in the formulary does not
12-5 guarantee that a
provider of health care will prescribe that drug for a
12-6 particular
medical condition.
12-7 Sec. 27. 1. Except as otherwise provided in this section, a health
12-8 care plan which
provides coverage for prescription drugs must not limit
12-9 or exclude
coverage for a drug if the drug:
12-10 (a) Had previously been approved for coverage
by the managed care
12-11 organization for
a medical condition of an insured and the insured’s
12-12 provider of
health care continues to prescribe the drug for the medical
12-13 condition; and
12-14 (b) Is appropriately prescribed and considered
safe and effective for
12-15 treating the
medical condition of the insured.
12-16 2. The
provisions of subsection 1 do not:
12-17 (a) Apply to coverage for any drug that is
prescribed for a use that is
12-18 different from
the use for which that drug has been approved for
12-19 marketing by the
Food and Drug Administration; or
12-20 (b) Prohibit:
12-21 (1) The organization from charging a
deductible, copayment or
12-22 coinsurance for
the provision of benefits for prescription drugs to the
12-23 insured or from
establishing, by contract, limitations on the maximum
12-24 coverage for
prescription drugs;
12-25 (2) A provider of health care from
prescribing another drug covered
12-26 by the plan that
is medically appropriate for the insured; or
12-27 (3) The substitution of another drug pursuant
to NRS 639.23286 or
12-28 639.2583 to
639.2599, inclusive.
12-29 3. Any
provision of a health care plan subject to the provisions of
12-30 this chapter that
is delivered, issued for delivery or renewed on or after
12-31 October 1, 2001,
which is in conflict with this section is void.
~