§2040.80. Access to Covered Prescription Drugs

 

This Section applies to health insurance coverage that covers prescription drugs.

 

a)         An issuer shall cover off-formulary prescription drugs if there is not a formulary drug available to treat the insured. The issuer shall do so without any prior authorization or step-therapy requirements that are separate from or redundant to any requirements already satisfied for the unavailable formulary drug. No greater cost-sharing shall be imposed than would apply to the formulary drug. Group health insurance coverage is subject to this subsection even if it is not provided by a health maintenance organization.

 

b)         To the extent consistent with clinical guidelines, an issuer shall cover an insured to obtain at least a 90-day supply upon refill of a covered maintenance medication, though exceptions may be made for drug classes that are prone to misuse, such as opioids, benzodiazepines, and stimulants. Group health insurance coverage is subject to this subsection only if it is provided by a health maintenance organization.