Louisiana Administrative Code
Title 37 - INSURANCE Part
Part XIII - Regulations
Chapter 141 - Regulation Number 100-Coverage of Prescription Drugs through a Drug Formulary
Section XIII-14113 - Enrollee's Right to Appeal Adverse Determination

Universal Citation: LA Admin Code XIII-14113

Current through Register Vol. 50, No. 9, September 20, 2024

A. The refusal of a health insurance issuer to provide benefits to an enrollee for a prescription drug is an adverse determination for the purposes of Subpart F of Part III of Chapter 4 of the Louisiana Insurance Code, R.S. 22:1121 et seq., relative to medical necessity review organizations, if each of the following conditions is met.

1. The drug is not included in a drug formulary used by the health benefit plan.

2. The enrollee's physician or other authorized prescriber has determined the drug is medically necessary.

B. An enrollee may appeal the adverse determination pursuant to subpart F of part III of chapter 4 of the Louisiana Insurance Code, R.S. 22:1121 et seq., relative to medical necessity review organizations.

AUTHORITY NOTE: Promulgated in accordance with R.S. 22:11, R.S. 22:1068(F) and R.S. 22:1074(F).

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