Senate Bill No. 2–Senator Amodei

 

CHAPTER..........

 

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

1-6   an 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, Green numbers along left margin indicate location on the printed bill (e.g., 5-15 indicates page 5, line 15).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;

1-18   and

1-19      (2) The telephone number of the insurer for making a request for

1-20   information regarding the formulary pursuant to subsection 2.

1-21    2.  If an insurer offers or issues a policy of health insurance which

1-22   provides coverage for prescription drugs and a formulary is used, the

1-23   insurer shall:

1-24    (a) Provide to any insured or participating provider of health care,

1-25   upon request:

1-26      (1) Information regarding whether a specific drug is included in the

1-27   formulary.

1-28      (2) Access to the most current list of prescription drugs in the

1-29   formulary, organized by major therapeutic category, with an indication

1-30   of whether any listed drugs are preferred over other listed drugs. If more

1-31   than one formulary is maintained, the insurer shall notify the requester

1-32   that a choice of formulary lists is available.

1-33    (b) Notify each person who requests information regarding the

1-34   formulary, that the inclusion of a drug in the formulary does not

1-35   guarantee that a provider of health care will prescribe that drug for a

1-36   particular medical condition.

1-37    Sec. 3.  1.  Except as otherwise provided in this section, a policy of

1-38   health insurance which provides coverage for prescription drugs must

1-39   not limit or exclude coverage for a drug if the drug:

1-40    (a) Had previously been approved for coverage by the insurer for a

1-41   medical condition of an insured and the insured’s provider of health

1-42   care determines, after conducting a reasonable investigation, that none

1-43   of the

2-1  drugs which are otherwise currently approved for coverage are medically

2-2  appropriate for the insured; and

2-3    (b) Is appropriately prescribed and considered safe and effective for

2-4   treating the medical condition of the insured.

2-5    2.  The provisions of subsection 1 do not:

2-6    (a) Apply to coverage for any drug that is prescribed for a use that is

2-7   different from the use for which that drug has been approved for

2-8   marketing by the Food and Drug Administration;

2-9    (b) Prohibit:

2-10      (1) The insurer from charging a deductible, copayment or

2-11   coinsurance for the provision of benefits for prescription drugs to the

2-12   insured or from establishing, by contract, limitations on the maximum

2-13   coverage for prescription drugs;

2-14      (2) A provider of health care from prescribing another drug covered

2-15   by the policy that is medically appropriate for the insured; or

2-16      (3) The substitution of another drug pursuant to NRS 639.23286 or

2-17   639.2583 to 639.2599, inclusive; or

2-18    (c) Require any coverage for a drug after the term of the policy.

2-19    3.  Any provision of a policy subject to the provisions of this chapter

2-20   that is delivered, issued for delivery or renewed on or after October 1,

2-21   2001, which is in conflict with this section is void.

2-22    Sec. 4.  Chapter 689B of NRS is hereby amended by adding thereto

2-23   the provisions set forth as sections 5 and 6 of this act.

2-24    Sec. 5.  1.  An insurer that offers or issues a policy of group health

2-25   insurance which provides coverage for prescription drugs shall include

2-26   with any summary, certificate or evidence of that coverage provided to

2-27   an insured, notice of whether a formulary is used and, if so, of the

2-28   opportunity to secure information regarding the formulary from the

2-29   insurer pursuant to subsection 2. The notice required by this subsection

2-30   must:

2-31    (a) Be in a language that is easily understood and in a format that is

2-32   easy to understand;

2-33    (b) Include an explanation of what a formulary is; and

2-34    (c) If a formulary is used, include:

2-35      (1) An explanation of:

2-36         (I) How often the contents of the formulary are reviewed; and

2-37         (II) The procedure and criteria for determining which

2-38   prescription drugs are included in and excluded from the formulary;

2-39   and

2-40      (2) The telephone number of the insurer for making a request for

2-41   information regarding the formulary pursuant to subsection 2.

2-42    2.  If an insurer offers or issues a policy of group health insurance

2-43   which provides coverage for prescription drugs and a formulary is used,

2-44   the insurer shall:

2-45    (a) Provide to any insured or participating provider of health care,

2-46   upon request:

2-47      (1) Information regarding whether a specific drug is included in the

2-48   formulary.

2-49      (2) Access to the most current list of prescription drugs in the

2-50   formulary, organized by major therapeutic category, with an indication

2-51   of whether any listed drugs are preferred over other listed drugs. If more

3-1  than one formulary is maintained, the insurer shall notify the requester

3-2  that a choice of formulary lists is available.

3-3    (b) Notify each person who requests information regarding the

3-4   formulary, that the inclusion of a drug in the formulary does not

3-5   guarantee that a provider of health care will prescribe that drug for a

3-6   particular medical condition.

3-7    Sec. 6.  1.  Except as otherwise provided in this section, a policy of

3-8   group health insurance which provides coverage for prescription drugs

3-9   must not limit or exclude coverage for a drug if the drug:

3-10    (a) Had previously been approved for coverage by the insurer for a

3-11   medical condition of an insured and the insured’s provider of health

3-12   care determines, after conducting a reasonable investigation, that none

3-13   of the drugs which are otherwise currently approved for coverage are

3-14   medically appropriate for the insured; and

3-15    (b) Is appropriately prescribed and considered safe and effective for

3-16   treating the medical condition of the insured.

3-17    2.  The provisions of subsection 1 do not:

3-18    (a) Apply to coverage for any drug that is prescribed for a use that is

3-19   different from the use for which that drug has been approved for

3-20   marketing by the Food and Drug Administration;

3-21    (b) Prohibit:

3-22      (1) The insurer from charging a deductible, copayment or

3-23   coinsurance for the provision of benefits for prescription drugs to the

3-24   insured or from establishing, by contract, limitations on the maximum

3-25   coverage for prescription drugs;

3-26      (2) A provider of health care from prescribing another drug covered

3-27   by the policy that is medically appropriate for the insured; or

3-28      (3) The substitution of another drug pursuant to NRS 639.23286 or

3-29   639.2583 to 639.2599, inclusive; or

3-30    (c) Require any coverage for a drug after the term of the policy.

3-31    3.  Any provision of a policy subject to the provisions of this chapter

3-32   that is delivered, issued for delivery or renewed on or after October 1,

3-33   2001, which is in conflict with this section is void.

3-34    Sec. 7.  Chapter 689C of NRS is hereby amended by adding thereto

3-35   the provisions set forth as sections 8, 9 and 10 of this act.

3-36    Sec. 8.  1.  A carrier that offers or issues a health benefit plan

3-37   which provides coverage for prescription drugs shall include with any

3-38   summary, certificate or evidence of that coverage provided to an insured,

3-39   notice of whether a formulary is used and, if so, of the opportunity to

3-40   secure information regarding the formulary from the carrier pursuant to

3-41   subsection 2. The notice required by this subsection must:

3-42    (a) Be in a language that is easily understood and in a format that is

3-43   easy to understand;

3-44    (b) Include an explanation of what a formulary is; and

3-45    (c) If a formulary is used, include:

3-46      (1) An explanation of:

3-47         (I) How often the contents of the formulary are reviewed; and

3-48         (II) The procedure and criteria for determining which

3-49   prescription drugs are included in and excluded from the formulary;

3-50   and

4-1       (2) The telephone number of the carrier for making a request for

4-2  information regarding the formulary pursuant to subsection 2.

4-3    2.  If a carrier offers or issues a health benefit plan which provides

4-4   coverage for prescription drugs and a formulary is used, the carrier

4-5   shall:

4-6    (a) Provide to any insured or participating provider of health care,

4-7   upon request:

4-8       (1) Information regarding whether a specific drug is included in the

4-9   formulary.

4-10      (2) Access to the most current list of prescription drugs in the

4-11   formulary, organized by major therapeutic category, with an indication

4-12   of whether any listed drugs are preferred over other listed drugs. If more

4-13   than one formulary is maintained, the carrier shall notify the requester

4-14   that a choice of formulary lists is available.

4-15    (b) Notify each person who requests information regarding the

4-16   formulary, that the inclusion of a drug in the formulary does not

4-17   guarantee that a provider of health care will prescribe that drug for a

4-18   particular medical condition.

4-19    Sec. 9.  1.  Except as otherwise provided in this section, a health

4-20   benefit plan which provides coverage for prescription drugs must not

4-21   limit or exclude coverage for a drug if the drug:

4-22    (a) Had previously been approved for coverage by the carrier for a

4-23   medical condition of an insured and the insured’s provider of health

4-24   care determines, after conducting a reasonable investigation, that none

4-25   of the drugs which are otherwise currently approved for coverage are

4-26   medically appropriate for the insured; and

4-27    (b) Is appropriately prescribed and considered safe and effective for

4-28   treating the medical condition of the insured.

4-29    2.  The provisions of subsection 1 do not:

4-30    (a) Apply to coverage for any drug that is prescribed for a use that is

4-31   different from the use for which that drug has been approved for

4-32   marketing by the Food and Drug Administration;

4-33    (b) Prohibit:

4-34      (1) The carrier from charging a deductible, copayment or

4-35   coinsurance for the provision of benefits for prescription drugs to the

4-36   insured or from establishing, by contract, limitations on the maximum

4-37   coverage for prescription drugs;

4-38      (2) A provider of health care from prescribing another drug covered

4-39   by the plan that is medically appropriate for the insured; or

4-40      (3) The substitution of another drug pursuant to NRS 639.23286 or

4-41   639.2583 to 639.2599, inclusive; or

4-42    (c) Require any coverage for a drug after the term of the plan.

4-43    3.  Any provision of a health benefit plan subject to the provisions of

4-44   this chapter that is delivered, issued for delivery or renewed on or after

4-45   October 1, 2001, which is in conflict with this section is void.

4-46    Sec. 10.  1.  A carrier that offers or issues a contract which provides

4-47   coverage for prescription drugs shall include with any summary,

4-48   certificate or evidence of that coverage provided to an insured, notice of

4-49   whether a formulary is used and, if so, of the opportunity to secure

5-1  information regarding the formulary from the carrier pursuant to

5-2  subsection 2. The notice required by this subsection must:

5-3    (a) Be in a language that is easily understood and in a format that is

5-4   easy to understand;

5-5    (b) Include an explanation of what a formulary is; and

5-6    (c) If a formulary is used, include:

5-7       (1) An explanation of:

5-8          (I) How often the contents of the formulary are reviewed; and

5-9          (II) The procedure and criteria for determining which

5-10   prescription drugs are included in and excluded from the formulary;

5-11   and

5-12      (2) The telephone number of the carrier for making a request for

5-13   information regarding the formulary pursuant to subsection 2.

5-14    2.  If a carrier offers or issues a contract which provides coverage for

5-15   prescription drugs and a formulary is used, the carrier shall:

5-16    (a) Provide to any insured or participating provider of health care,

5-17   upon request:

5-18      (1) Information regarding whether a specific drug is included in the

5-19   formulary.

5-20      (2) Access to the most current list of prescription drugs in the

5-21   formulary, organized by major therapeutic category, with an indication

5-22   of whether any listed drugs are preferred over other listed drugs. If more

5-23   than one formulary is maintained, the carrier shall notify the requester

5-24   that a choice of formulary lists is available.

5-25    (b) Notify each person who requests information regarding the

5-26   formulary, that the inclusion of a drug in the formulary does not

5-27   guarantee that a provider of health care will prescribe that drug for a

5-28   particular medical condition.

5-29    Sec. 11.  NRS 689C.425 is hereby amended to read as follows:

5-30    689C.425  A voluntary purchasing group and any contract issued to

5-31   such a group pursuant to NRS 689C.360 to 689C.600, inclusive, and

5-32   section 10 of this act are subject to the provisions of NRS 689C.015 to

5-33   689C.355, inclusive, and sections 8 and 9 of this act to the extent

5-34   applicable and not in conflict with the express provisions of NRS

5-35   689C.360 to 689C.600, inclusive, and [this section.] section 10 of this act.

5-36    Sec. 12.  Chapter 695A of NRS is hereby amended by adding thereto

5-37   the provisions set forth as sections 13 and 14 of this act.

5-38    Sec. 13.  1.  A society that offers or issues a benefit contract which

5-39   provides coverage for prescription drugs shall include with any

5-40   certificate for such a contract provided to a benefit member, notice of

5-41   whether a formulary is used and, if so, of the opportunity to secure

5-42   information regarding the formulary from the society pursuant to

5-43   subsection 2. The notice required by this subsection must:

5-44    (a) Be in a language that is easily understood and in a format that is

5-45   easy to understand;

5-46    (b) Include an explanation of what a formulary is; and

5-47    (c) If a formulary is used, include:

5-48      (1) An explanation of:

5-49         (I) How often the contents of the formulary are reviewed; and

5-50         (II) The procedure and criteria for determining which

5-51   prescription drugs are included in and excluded from the formulary;

5-52   and

6-1       (2) The telephone number of the society for making a request for

6-2  information regarding the formulary pursuant to subsection 2.

6-3    2.  If a society offers or issues a benefit contract which provides

6-4   coverage for prescription drugs and a formulary is used, the society

6-5   shall:

6-6    (a) Provide to any insured or participating provider of health care,

6-7   upon request:

6-8       (1) Information regarding whether a specific drug is included in the

6-9   formulary.

6-10      (2) Access to the most current list of prescription drugs in the

6-11   formulary, organized by major therapeutic category, with an indication

6-12   of whether any listed drugs are preferred over other listed drugs. If more

6-13   than one formulary is maintained, the society shall notify the requester

6-14   that a choice of formulary lists is available.

6-15    (b) Notify each person who requests information regarding the

6-16   formulary, that the inclusion of a drug in the formulary does not

6-17   guarantee that a provider of health care will prescribe that drug for a

6-18   particular medical condition.

6-19    Sec. 14.  1.  Except as otherwise provided in this section, a benefit

6-20   contract which provides coverage for prescription drugs must not limit

6-21   or exclude coverage for a drug if the drug:

6-22    (a) Had previously been approved for coverage by the society for a

6-23   medical condition of an insured and the insured’s provider of health

6-24   care determines, after conducting a reasonable investigation, that none

6-25   of the drugs which are otherwise currently approved for coverage are

6-26   medically appropriate for the insured; and

6-27    (b) Is appropriately prescribed and considered safe and effective for

6-28   treating the medical condition of the insured.

6-29    2.  The provisions of subsection 1 do not:

6-30    (a) Apply to coverage for any drug that is prescribed for a use that is

6-31   different from the use for which that drug has been approved for

6-32   marketing by the Food and Drug Administration;

6-33    (b) Prohibit:

6-34      (1) The society from charging a deductible, copayment or

6-35   coinsurance for the provision of benefits for prescription drugs to the

6-36   insured or from establishing, by contract, limitations on the maximum

6-37   coverage for prescription drugs;

6-38      (2) A provider of health care from prescribing another drug covered

6-39   by the benefit contract that is medically appropriate for the insured; or

6-40      (3) The substitution of another drug pursuant to NRS 639.23286 or

6-41   639.2583 to 639.2599, inclusive; or

6-42    (c) Require any coverage for a drug after the term of the benefit

6-43   contract.

6-44    3.  Any provision of a benefit contract subject to the provisions of this

6-45   chapter that is delivered, issued for delivery or renewed on or after

6-46   October 1, 2001, which is in conflict with this section is void.

6-47    Sec. 15.  Chapter 695B of NRS is hereby amended by adding thereto

6-48   the provisions set forth as sections 16 and 17 of this act.

 

7-1    Sec. 16.  1.  An insurer that offers or issues a contract for hospital

7-2  or medical services which provides coverage for prescription drugs shall

7-3   include with any summary, certificate or evidence of that coverage

7-4   provided to an insured, notice of whether a formulary is used and, if so,

7-5   of the opportunity to secure information regarding the formulary from

7-6   the insurer pursuant to subsection 2. The notice required by this

7-7   subsection must:

7-8    (a) Be in a language that is easily understood and in a format that is

7-9   easy to understand;

7-10    (b) Include an explanation of what a formulary is; and

7-11    (c) If a formulary is used, include:

7-12      (1) An explanation of:

7-13         (I) How often the contents of the formulary are reviewed; and

7-14         (II) The procedure and criteria for determining which

7-15   prescription drugs are included in and excluded from the formulary;

7-16   and

7-17      (2) The telephone number of the insurer for making a request for

7-18   information regarding the formulary pursuant to subsection 2.

7-19    2.  If an insurer offers or issues a contract for hospital or medical

7-20   services which provides coverage for prescription drugs and a formulary

7-21   is used, the insurer shall:

7-22    (a) Provide to any insured or participating provider of health care,

7-23   upon request:

7-24      (1) Information regarding whether a specific drug is included in the

7-25   formulary.

7-26      (2) Access to the most current list of prescription drugs in the

7-27   formulary, organized by major therapeutic category, with an indication

7-28   of whether any listed drugs are preferred over other listed drugs. If more

7-29   than one formulary is maintained, the insurer shall notify the requester

7-30   that a choice of formulary lists is available.

7-31    (b) Notify each person who requests information regarding the

7-32   formulary, that the inclusion of a drug in the formulary does not

7-33   guarantee that a provider of health care will prescribe that drug for a

7-34   particular medical condition.

7-35    Sec. 17.  1.  Except as otherwise provided in this section, a contract

7-36   for hospital or medical services which provides coverage for prescription

7-37   drugs must not limit or exclude coverage for a drug if the drug:

7-38    (a) Had previously been approved for coverage by the insurer for a

7-39   medical condition of an insured and the insured’s provider of health

7-40   care determines, after conducting a reasonable investigation, that none

7-41   of the drugs which are otherwise currently approved for coverage are

7-42   medically appropriate for the insured; and

7-43    (b) Is appropriately prescribed and considered safe and effective for

7-44   treating the medical condition of the insured.

7-45    2.  The provisions of subsection 1 do not:

7-46    (a) Apply to coverage for any drug that is prescribed for a use that is

7-47   different from the use for which that drug has been approved for

7-48   marketing by the Food and Drug Administration;

7-49    (b) Prohibit:

7-50      (1) The insurer from charging a deductible, copayment or

7-51   coinsurance for the provision of benefits for prescription drugs to the

8-1  insured or from establishing, by contract, limitations on the maximum

8-2  coverage for prescription drugs;

8-3       (2) A provider of health care from prescribing another drug covered

8-4   by the contract that is medically appropriate for the insured; or

8-5       (3) The substitution of another drug pursuant to NRS 639.23286 or

8-6   639.2583 to 639.2599, inclusive; or

8-7    (c) Require any coverage for a drug after the term of the contract.

8-8    3.  Any provision of a contract for hospital or medical services subject

8-9   to the provisions of this chapter that is delivered, issued for delivery or

8-10   renewed on or after October 1, 2001, which is in conflict with this

8-11   section is void.

8-12    Sec. 18.  Chapter 695C of NRS is hereby amended by adding thereto

8-13   the provisions set forth as sections 19 and 20 of this act.

8-14    Sec. 19.  1.  A health maintenance organization or insurer that

8-15   offers or issues evidence of coverage which provides coverage for

8-16   prescription drugs shall include with any evidence of that coverage

8-17   provided to an enrollee, notice of whether a formulary is used and, if so,

8-18   of the opportunity to secure information regarding the formulary from

8-19   the organization or insurer pursuant to subsection 2. The notice

8-20   required by this subsection must:

8-21    (a) Be in a language that is easily understood and in a format that is

8-22   easy to understand;

8-23    (b) Include an explanation of what a formulary is; and

8-24    (c) If a formulary is used, include:

8-25      (1) An explanation of:

8-26         (I) How often the contents of the formulary are reviewed; and

8-27         (II) The procedure and criteria for determining which

8-28   prescription drugs are included in and excluded from the formulary;

8-29   and

8-30      (2) The telephone number of the organization or insurer for

8-31   making a request for information regarding the formulary pursuant to

8-32   subsection 2.

8-33    2.  If a health maintenance organization or insurer offers or issues

8-34   evidence of coverage which provides coverage for prescription drugs and

8-35   a formulary is used, the organization or insurer shall:

8-36    (a) Provide to any enrollee or participating provider of health care

8-37   upon request:

8-38      (1) Information regarding whether a specific drug is included in the

8-39   formulary.

8-40      (2) Access to the most current list of prescription drugs in the

8-41   formulary, organized by major therapeutic category, with an indication

8-42   of whether any listed drugs are preferred over other listed drugs. If more

8-43   than one formulary is maintained, the organization or insurer shall

8-44   notify the requester that a choice of formulary lists is available.

8-45    (b) Notify each person who requests information regarding the

8-46   formulary, that the inclusion of a drug in the formulary does not

8-47   guarantee that a provider of health care will prescribe that drug for a

8-48   particular medical condition.

8-49    Sec. 20.  1.  Except as otherwise provided in this section, evidence

8-50   of coverage which provides coverage for prescription drugs must not

8-51   limit or exclude coverage for a drug if the drug:

9-1    (a) Had previously been approved for coverage by the health

9-2  maintenance organization or insurer for a medical condition of an

9-3   enrollee and the enrollee’s provider of health care determines, after

9-4   conducting a reasonable investigation, that none of the drugs which are

9-5   otherwise currently approved for coverage are medically appropriate for

9-6   the enrollee; and

9-7    (b) Is appropriately prescribed and considered safe and effective for

9-8   treating the medical condition of the enrollee.

9-9    2.  The provisions of subsection 1 do not:

9-10    (a) Apply to coverage for any drug that is prescribed for a use that is

9-11   different from the use for which that drug has been approved for

9-12   marketing by the Food and Drug Administration;

9-13    (b) Prohibit:

9-14      (1) The health maintenance organization or insurer from charging

9-15   a deductible, copayment or coinsurance for the provision of benefits for

9-16   prescription drugs to the enrollee or from establishing, by contract,

9-17   limitations on the maximum coverage for prescription drugs;

9-18      (2) A provider of health care from prescribing another drug covered

9-19   by the evidence of coverage that is medically appropriate for the

9-20   enrollee; or

9-21      (3) The substitution of another drug pursuant to NRS 639.23286 or

9-22   639.2583 to 639.2599, inclusive; or

9-23    (c) Require any coverage for a drug after the term of the evidence of

9-24   coverage.

9-25    3.  Any provision of an evidence of coverage subject to the provisions

9-26   of this chapter that is delivered, issued for delivery or renewed on or

9-27   after October 1, 2001, which is in conflict with this section is void.

9-28    Sec. 21.  NRS 695C.050 is hereby amended to read as follows:

9-29    695C.050  1.  Except as otherwise provided in this chapter or in

9-30   specific provisions of this Title, the provisions of this Title are not

9-31   applicable to any health maintenance organization granted a certificate of

9-32   authority under this chapter. This provision does not apply to an insurer

9-33   licensed and regulated pursuant to this Title except with respect to its

9-34   activities as a health maintenance organization authorized and regulated

9-35   pursuant to this chapter.

9-36    2.  Solicitation of enrollees by a health maintenance organization

9-37   granted a certificate of authority, or its representatives, must not be

9-38   construed to violate any provision of law relating to solicitation or

9-39   advertising by practitioners of a healing art.

9-40    3.  Any health maintenance organization authorized under this chapter

9-41   shall not be deemed to be practicing medicine and is exempt from the

9-42   provisions of chapter 630 of NRS.

9-43    4.  The provisions of NRS 695C.110, 695C.170 to 695C.200, inclusive,

9-44   and sections 19 and 20 of this act, NRS 695C.250 and 695C.265 do not

9-45   apply to a health maintenance organization that provides health care

9-46   services through managed care to recipients of Medicaid under the state

9-47   plan for Medicaid or insurance pursuant to the children’s health insurance

9-48   program pursuant to a contract with the division of health care financing

9-49   and policy of the department of human resources. This subsection does not

10-1  exempt a health maintenance organization from any provision of this

10-2  chapter for services provided pursuant to any other contract.

10-3    5.  The provisions of NRS 695C.1694 and 695C.1695 apply to a health

10-4   maintenance organization that provides health care services through

10-5   managed care to recipients of Medicaid under the state plan for Medicaid.

10-6    Sec. 22.  Chapter 695F of NRS is hereby amended by adding thereto

10-7   the provisions set forth as sections 23 and 24 of this act.

10-8    Sec. 23.  1.  A prepaid limited health service organization that offers

10-9   or issues evidence of coverage which provides coverage for prescription

10-10   drugs shall include with any evidence of that coverage provided to a

10-11   subscriber, notice of whether a formulary is used and, if so, of the

10-12   opportunity to secure information regarding the formulary from the

10-13   organization pursuant to subsection 2. The notice required by this

10-14   subsection must:

10-15  (a) Be in a language that is easily understood and in a format that is

10-16   easy to understand;

10-17  (b) Include an explanation of what a formulary is; and

10-18  (c) If a formulary is used, include:

10-19     (1) An explanation of:

10-20        (I) How often the contents of the formulary are reviewed; and

10-21        (II) The procedure and criteria for determining which

10-22   prescription drugs are included in and excluded from the formulary;

10-23   and

10-24     (2) The telephone number of the organization for making a request

10-25   for information regarding the formulary pursuant to subsection 2.

10-26  2.  If a prepaid limited health service organization offers or issues

10-27   evidence of coverage which provides coverage for prescription drugs and

10-28   a formulary is used, the organization shall:

10-29  (a) Provide to any enrollee or participating provider of health care,

10-30   upon request:

10-31     (1) Information regarding whether a specific drug is included in the

10-32   formulary.

10-33     (2) Access to the most current list of prescription drugs in the

10-34   formulary, organized by major therapeutic category, with an indication

10-35   of whether any listed drugs are preferred over other listed drugs. If more

10-36   than one formulary is maintained, the organization shall notify the

10-37   requester that a choice of formulary lists is available.

10-38  (b) Notify each person who requests information regarding the

10-39   formulary, that the inclusion of a drug in the formulary does not

10-40   guarantee that a provider of health care will prescribe that drug for a

10-41   particular medical condition.

10-42  Sec. 24.  1.  Except as otherwise provided in this section, evidence

10-43   of coverage which provides coverage for prescription drugs must not

10-44   limit or exclude coverage for a drug if the drug:

10-45  (a) Had previously been approved for coverage by the prepaid limited

10-46   health service organization for a medical condition of an enrollee and

10-47   the enrollee’s provider of health care determines, after conducting a

10-48   reasonable investigation, that none of the drugs which are otherwise

10-49   currently approved for coverage are medically appropriate for the

10-50   enrollee; and

11-1    (b) Is appropriately prescribed and considered safe and effective for

11-2  treating the medical condition of the enrollee.

11-3    2.  The provisions of subsection 1 do not:

11-4    (a) Apply to coverage for any drug that is prescribed for a use that is

11-5   different from the use for which that drug has been approved for

11-6   marketing by the Food and Drug Administration;

11-7    (b) Prohibit:

11-8      (1) The organization from charging a deductible, copayment or

11-9   coinsurance for the provision of benefits for prescription drugs to the

11-10   enrollee or from establishing, by contract, limitations on the maximum

11-11   coverage for prescription drugs;

11-12     (2) A provider of health care from prescribing another drug covered

11-13   by the evidence of coverage that is medically appropriate for the

11-14   enrollee; or

11-15     (3) The substitution of another drug pursuant to NRS 639.23286 or

11-16   639.2583 to 639.2599, inclusive; or

11-17  (c) Require any coverage for a drug after the term of the evidence of

11-18   coverage.

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

11-21   after 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;

11-39   and

11-40     (2) The telephone number of the organization for making a request

11-41   for information regarding the formulary pursuant to subsection 2.

11-42  2.  If a managed care organization offers or issues a health care plan

11-43   which provides coverage for prescription drugs and a formulary is used,

11-44   the organization shall:

11-45  (a) Provide to any insured or participating provider of health care,

11-46   upon request:

11-47     (1) Information regarding whether a specific drug is included in the

11-48   formulary.

11-49     (2) Access to the most current list of prescription drugs in the

11-50   formulary, organized by major therapeutic category, with an indication

11-51   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 determines, after conducting a reasonable

12-13   investigation, that none of the drugs which are otherwise currently

12-14   approved for coverage are medically appropriate for the insured; and

12-15  (b) Is appropriately prescribed and considered safe and effective for

12-16   treating the medical condition of the insured.

12-17  2.  The provisions of subsection 1 do not:

12-18  (a) Apply to coverage for any drug that is prescribed for a use that is

12-19   different from the use for which that drug has been approved for

12-20   marketing by the Food and Drug Administration;

12-21  (b) Prohibit:

12-22     (1) The organization from charging a deductible, copayment or

12-23   coinsurance for the provision of benefits for prescription drugs to the

12-24   insured or from establishing, by contract, limitations on the maximum

12-25   coverage for prescription drugs;

12-26     (2) A provider of health care from prescribing another drug covered

12-27   by the plan that is medically appropriate for the insured; or

12-28     (3) The substitution of another drug pursuant to NRS 639.23286 or

12-29   639.2583 to 639.2599, inclusive; or

12-30  (c) Require any coverage for a drug after the term of the plan.

12-31  3.  Any provision of a health care plan subject to the provisions of

12-32   this chapter that is delivered, issued for delivery or renewed on or after

12-33   October 1, 2001, which is in conflict with this section is void.

 

12-34  ²⁰~~~~~⁰¹