RS 22:1060.4: Adverse determination

A. The refusal of a health insurance issuer to provide benefits to an enrollee for a prescription drug is an adverse determination for purposes of the Internal Claims and Appeals Process and External Review Act, R.S. 22:2391 et seq., 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. The enrollee may appeal the adverse determination pursuant to the Internal Claims and Appeals Process and External Review Act, R.S. 22:2391 et seq.