A. A managed care plan that has a closed formulary or that requires prior authorization to obtain certain drugs shall approve or disapprove a provider’s or a covered person’s request for a nonformulary drug or a drug that requires prior authorization within twenty-four (24) hours of receipt of such request.
B. If the managed care plan does not render a decision within twenty-four (24) hours, the provider or covered person shall be entitled to a seventy-two-hour supply of the drug. The managed care plan shall then approve or disapprove the request for a nonformulary drug or prior authorized drug within the additional seventy-two-hour period.
C. Failure of the managed care plan to respond within the subsequently allowed seventy-two-hour period shall be deemed as approval of the request for the nonformulary drug or prior authorized drug; provided, however, the approval shall be subject to the terms of the managed care plan’s drug formulary; provided further, the purchase of the approved drug shall be at no additional cost to the covered person beyond what the covered person would otherwise pay for a prescription pursuant to the managed care plan.
D. All providers and covered persons in a managed care plan shall be provided with a copy of the plan’s drug prior authorization process upon initial contracting or enrollment and at the time of enactment of any subsequent changes to the process.
Added by Laws 1999, c. 361, § 4, eff. Nov. 1, 1999.
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