2014 New Hampshire Revised Statutes
Title XXXVII - INSURANCE
Chapter 420-J - MANAGED CARE LAW
Section 420-J:7-b - Prescription Drugs.

    420-J:7-b Prescription Drugs. –
    I. (a) Every health benefit plan that provides prescription drug benefits is required to provide prospective enrollees, and covered persons, a description of the prescription drug benefit plan. Among the specific items that shall be included in the description are:
          (1) The procedure a covered person must follow to obtain drugs and medications that are subject to a plan list or plan formulary.
          (2) A description of the drug formulary and the plan's exception process.
          (3) A description of the extent to which a covered person will be reimbursed for the cost of a drug that is not on a plan list or formulary.
       (b) Health carriers shall provide upon request additional information to covered persons related to specific drugs that are not on the formulary.
    II. Every health benefit plan that provides prescription drug benefits shall maintain an expeditious exception process, not to exceed 48 hours, by which covered persons may obtain coverage for a medically necessary nonformulary prescription drug. The exception process shall begin when the prescribing provider has submitted a request with a clinical rationale for the exception to the health benefit plan. A prescription that requires an exception for coverage shall be considered approved if the exception process exceeds 48 hours.
    II-a. No health benefit plan that provides prescription drug benefits and establishes the specific sequence in which prescription drugs for a medical condition are to be prescribed shall require failure on the same medication on more than one occasion for patients continuously enrolled in the plan. Nothing in this section shall be construed to prevent a health care provider from prescribing a medication to the same patient on more than one occasion, when he or she determines it is medically appropriate.
    III. Every health plan that provides prescription drug benefits shall notify covered persons affected by deletions to the plan list or plan formulary, provide an explanation of the exception process by which a covered person can access nonformulary medically necessary prescription drugs, and provide a toll-free telephone number through which a covered person can request additional information. For purposes of this paragraph, covered persons affected by deletions to the plan list or plan formulary shall include those covered persons for whom the health plan has provided coverage for the deleted prescription drugs during the 12-month period immediately prior to the deletion. Upon notification to covered persons, the health benefit plan shall allow at least 45 days before implementation of any formulary deletions; provided, however, that advance notice shall not be required if the federal Food and Drug Administration has determined hat a prescription drug on the health benefit plan's formulary is unsafe.
    IV. Every health benefit plan that provides prescription drug benefits shall maintain, as part of its records, all of the following information, which shall be made available to the commissioner upon request: the complete drug formulary or formularies of the plan, if the plan maintains a formulary, including a list of the prescription drugs on the formulary of the plan by major therapeutic category with an indication of whether any drugs are preferred over the other drugs.
    IV-a. Every health benefit plan that provides prescription drug benefits shall provide notice of deletions to the plan list or plan formulary to all covered persons at least annually.
    IV-b. Every health benefit plan that provides prescription drug coverage shall also provide notice of additions to the plan list or formulary to all covered persons at least annually. However, the requirements of this paragraph shall not apply to any health benefit plan that adds prescription drugs to its plan list or formulary upon approval by the federal Food and Drug Association.
    V. Every health benefit plan that provides coverage for prescription drugs or devices, or administers such a plan, or which contracts with an entity providing such prescription drug coverage, including but not limited to pharmacy benefit manager companies, shall issue to covered persons a card or other technology containing uniform prescription drug information. The uniform prescription drug information card or technology shall include all of the fields required by the health insurance provider for claims processing in a clear, readable, and understandable manner on the card or other technology issued and shall include, at a minimum, the following information:
       (a) The name or trademark logo of the insurer and, if another company administers the prescription benefit, the name or trademark logo of the benefit administrator.
       (b) The covered person's name and identification number.
       (c) All of the electronic transaction routing information required by the insurer or its benefit administrator in order for the pharmacy to electronically process a prescription claim, including but not limited to the BIN number labeled as such or the Processor Control Number labeled as such, or both.
    VI. All subscriber health insurance cards issued after January 1, 2004 shall contain the information required under paragraph V.
    VII. A new uniform prescription drug information card, as required under paragraph V, shall be issued by health benefit plan upon enrollment of new members and when reissuing a new card to current members when there is a change in the covered person's pharmacy coverage that affects data contained on the card.
    VIII. Every health benefit plan that provides prescription drug benefits shall allow its covered persons to purchase an up-to-90-day supply of covered prescription drugs on the covered person's health benefit plan formulary at one time at a pharmacy of the insured's choice within the insurer's network, provided that the insured can demonstrate that such drug has been taken by the insured for a continuous period of one year and provided that such drug is not subject to the health benefit plan's utilization management, prior authorization, or pre-certification requirements. Controlled substances as identified by the United States Drug Enforcement Administration are exempt from this paragraph. Nothing in this paragraph shall be construed to limit the health benefit plan's ability to establish co-payments, coinsurance deductibles, or other member cost shares. A retail pharmacy dispensing a 90-day supply of covered prescription drugs under this paragraph shall comply with any specified terms, conditions, and reimbursement rate which the health benefit plan may require for mail order pharmacies that fill 90-day prescriptions.
    IX. (a) Every health benefit plan that provides prescription drug benefits shall allow its covered persons to obtain an emergency prescription for up to a 72-hour supply of covered prescription drugs on the covered person's health benefit plan formulary in the event a prescription requires prior authorization by an insurance carrier and the prior authorization has neither been approved nor denied and a pharmacist has determined the medication is essential as provided in RSA 318:47-i. Such reimbursement shall be according to the payment rates of the provider contract. If authorization is subsequently denied, the carrier shall reimburse the pharmacist for the prescription as given based on the pro-rated amount they would have otherwise received under the terms of the provider contract.
       (b) The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted:
          (1) Agents when used for anorexia, weight loss, or weight gain.
          (2) Agents when used to promote fertility.
          (3) Agents when used for cosmetic purposes or hair growth.
          (4) Agents when used for the symptomatic relief of cough and colds.
          (5) Agents when used to promote smoking cessation.
          (6) Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.
          (7) Nonprescription drugs, except, in the case of pregnant women when recommended by or under the supervision of a physician, agents approved by the Food and Drug Administration under the over-the-counter monograph process for purposes of promoting, and when used to promote, tobacco cessation.
          (8) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.
          (9) Barbiturates.
          (10) Benzodiazepines.
          (11) Agents when used for the treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the Food and Drug Administration.

Source. 2003, 286:5. 2004, 187:15-17, eff. July 31, 2004. 2007, 73:2, eff. Aug. 10, 2007. 2013, 257:30, eff. Sept. 22, 2013 at 12:01 a.m.; 262:1, eff. Sept. 22, 2013. 2014, 2:1, eff. April 21, 2014; 120:2, eff. Aug. 15, 2014; 311:3, eff. Jan. 1, 2015.