2016 Indiana Code
TITLE 27. INSURANCE
ARTICLE 13. HEALTH MAINTENANCE ORGANIZATIONS
CHAPTER 38. PATIENT PROTECTION; DRUGS AND DEVICES; DRUG UTILIZATION REVIEW PROGRAM
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<![CDATA[IC 27-13-38
Chapter 38. Patient Protection; Drugs and Devices; Drug
Utilization Review Program
IC 27-13-38-1
Drug and devices formularies
Sec. 1. (a) A health maintenance organization may apply a
formulary to the prescription drug and devices benefits provided by
the health maintenance organization if the formulary is developed,
reviewed, and updated:
(1) in consultation with; and
(2) with the approval of;
a pharmacy and therapeutics committee, a majority of whose
members are licensed physicians.
(b) If a health maintenance organization maintains one (1) or more
drug and devices formularies, the health maintenance organization
shall do the following:
(1) Disseminate to participating providers and pharmacists the
complete drug and devices formulary or formularies maintained
by the health maintenance organization, including a list of the
devices and prescription drugs on the formulary by major
therapeutic category that specifies whether a particular drug or
device is preferred over other drugs or devices.
(2) Establish and maintain an expeditious process or procedure
that allows an enrollee to obtain, without penalty or additional
cost sharing beyond that provided for in the enrollee's covered
benefits with the health maintenance organization, coverage for
a specific, medically necessary and appropriate nonformulary
drug or device without prior approval from the health
maintenance organization.
(c) A health maintenance organization may not:
(1) void a contract; or
(2) refuse to renew a contract;
between the health maintenance organization and a prescribing
provider because the prescribing provider has prescribed a medically
necessary and appropriate nonformulary drug or device as provided
in subsection (b)(2).
As added by P.L.69-1998, SEC.16.
IC 27-13-38-2
Substitution of brand name drugs
Sec. 2. Subject to IC 16-42-22:
(1) a pharmacist shall not substitute; and
(2) a health maintenance organization shall not require the
substitution of;
a different single source brand name drug for a single source brand
name drug written on a prescription form or electronically
transmitted to a pharmacy unless the substitution is approved by the
Indiana Code 2016
prescribing provider.
As added by P.L.69-1998, SEC.16. Amended by P.L.204-2005,
SEC.20.
IC 27-13-38-3
Drug utilization review programs; contents
Sec. 3. Each health maintenance organization that has a
prescription drug benefit shall establish and operate, or cause to be
established and operated, a drug utilization review program that
includes the following:
(1) Retrospective review of prescription drugs furnished to
enrollees.
(2) Education of physicians, enrollees, and pharmacists
regarding the appropriate use of prescription drugs.
(3) Ongoing periodic examination of data on outpatient
prescription drugs to ensure quality therapeutic outcomes for
enrollees.
(4) Clinically relevant criteria and standards for drug therapy.
(5) Nonproprietary criteria and standards, developed and
revised through an open, professional consensus process.
(6) Interventions that focus on improving therapeutic outcomes,
including prospective drug utilization review programs that
monitor for possible prescription drug problems or
complications, including drug to disease interactions, drug to
drug interactions, or therapeutic duplication.
As added by P.L.69-1998, SEC.16.
IC 27-13-38-4
Drug utilization review programs; primary emphasis
Sec. 4. The primary emphasis of the drug utilization review
program established under section 3 of this chapter is to enhance
quality of care for enrollees by assuring appropriate drug therapy.
As added by P.L.69-1998, SEC.16.
IC 27-13-38-5
Drug utilization review programs; confidentiality of enrollees
Sec. 5. The name of an enrollee that is discovered in the course of
the drug utilization review program shall remain confidential.
As added by P.L.69-1998, SEC.16.
IC 27-13-38-6
Adoption of rules
Sec. 6. The commissioner, with input and assistance from the state
health commissioner, may adopt rules under IC 4-22-2 to implement
this chapter.
As added by P.L.69-1998, SEC.16.
IC 27-13-38-7
Indiana Code 2016
Prescription drug coverage
Sec. 7. (a) The definitions in IC 27-13-7-23 apply throughout this
section.
(b) A health maintenance organization shall not remove a
prescription drug from the health maintenance organization's
formulary, change the cost sharing requirements that apply to a
prescription drug, or change the utilization review program
requirements that apply to a prescription drug unless that health
maintenance organization does at least one (1) of the following:
(1) At least sixty (60) days before the removal or change is
effective, send written notice of the removal or change to each
enrollee for whom the prescription drug has been prescribed
during the preceding twelve (12) month period.
(2) At the time an enrollee for whom the prescription drug has
been prescribed during the preceding twelve (12) month period
requests a refill of the prescription drug, provide to the enrollee:
(A) written notice of the removal or change; and
(B) a sixty (60) day supply of the prescription drug under the
terms that applied before the removal or change.
As added by P.L.19-2016, SEC.6.
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