Current through Register Vol. 46, No. 39, September 25, 2024
(a) Every insurer that delivers or issues for
delivery in this state an accident and health insurance policy that provides
hospital, surgical, or medical expense coverage and also provides coverage for
medication for the detoxification or maintenance treatment of a substance use
disorder shall include in the policy processes that allow an insured, the
insured's designee, or the insured's prescribing physician (or other
prescriber, as appropriate) to request a formulary exception and gain access to
clinically appropriate medication for the detoxification or maintenance
treatment of a substance use disorder not otherwise covered by the policy (a
request for formulary exception). With respect to the process for such a
formulary exception, an insurer shall follow the process an d procedures
specified in Insurance Law Article 49 or Public Health Law Article 49, as
applicable, except as otherwise provided in this section.
(b) Standard formulary exception request.
(1) An insurer shall have a process for an
insured, the insured's designee, or the insured's prescribing physician (or
other prescriber) to request a standard review of a decision that a medication
for the detoxification or maintenance treatment of a substance use disorder
drug is not covered by the policy.
(2) An insurer shall make a determination on
a standard exception request and notify the insured or the insured's designee
and the prescribing physician (or other prescriber, as appropriate) of its
coverage determination no later than 72 hours following receipt of the request.
(3) An insurer that grants a
standard exception request shall provide coverage of the non-formulary
medication for the detoxification or maintenance treatment of a substance use
disorder for the duration of the prescription, including refills.
(c) Expedited formulary exception
request.
(1) An insurer shall have a process
for an insured, the insured's designee, or the insured's prescribing physician
(or other prescriber) to request an expedited review of a decision that a
medication for the detoxification or maintenance treatment of a substance use
disorder is not covered by the policy based on exigent circumstances.
(2) Exigent circumstances exist when an
insured is suffering from a health condition that may seriously jeopardize the
insured's life, health, or ability to regain maximum function or when an
insured is undergoing a current course of treatment using a non-formulary
medication for the detoxification or maintenance treatment of a substance use
disorder.
(3) An insurer shall
make a determination on an expedited review request based on exigent
circumstances and notify the insured or the insured's designee and the
prescribing physician (or other prescriber, as appropriate) of its coverage
determination no later than 24 hours following receipt of the request.
(4) An insurer that grants an
exception based on exigent circumstances shall provide coverage of the
non-formulary medication for the detoxification or maintenance treatment of a
substance use disorder for the duration of the exigency.
(d) Notice. An insurer that denies an
exception request under subdivision (b) or (c) of this section shall provide
written notice of its determination to the insured or the insured's designee
and the prescribing physician (or other prescriber, as appropriate). The
written notice shall be considered a final adverse determination under
Insurance Law section 4904 or Public Health Law section 4904, as applicable.
Written notice shall also include the name or names of clinically appropriate
medications for the detoxification or maintenance treatment of a substance use
disorder covered by the insurer to treat the insured.
(e) External appeal.
(1) If an insurer denies a request for an
exception under subdivision (b) or (c) of this section, then the insurer shall
have a process for the insured, the insured's designee, or the insured's
prescribing physician (or other prescriber) to request that the denial of such
request be reviewed by an external appeal agent certified by the Superintendent
pursuant to Insurance Law section 4911 in accordance with Insurance Law Article
49 or Public Health Law Article 49, as appropriate.
(2) An external appeal agent shall make a
determination on the external appeal and notify the insurer, the insured or the
insured's designee, and the prescribing physician (or other prescriber, as
appropriate) of its determination no later than:
(i) 72 hours following the agent's receipt of
the request, if the original request was a standard exception request under
subdivision (b) of this section; or
(ii) 24 hours following the agent's receipt
of the request, if the original request was a n expedited exception request
under subdivision (c) of this section and the prescribing physician (or other
prescriber) attests that exigent circumstances exist.
(3) An external appeal agent shall make a
determination in accordance with Insurance Law section 4914(b)(4)(A) or Public
Health Law section 4914(2)(d)(A), as applicable. When making a determination,
the external appeal agent shall also consider whether the formulary medication
for the detoxification or maintenance treatment of a sub stance use disorder
covered by the insurer will be or has been ineffective, would not be as
effective as the non-formulary medication for the detoxification or maintenance
treatment of a substance use disorder, or would have adverse effects.
(4) If an external appeal agent
overturns the insurer's denial of a standard exception request under
subdivision (b) of this section, then the insurer shall provide coverage of the
non-formulary medication for the detoxification or maintenance treatment of a
substance use disorder for the duration of the prescription, including refills.
If an external appeal agent overturns the insurer's denial of an expedited
except ion request under subdivision (c) of this section, then the insurer
shall provide coverage of the non-formulary medication for the detoxification
or maintenance treatment of a substance use disorder for the duration of the
exige
