La. Admin. Code tit. 37 § XIII-14115

Current through Register Vol. 50, No. 11, November 20, 2024

Section XIII-14115 - Requirements for Modifying a Group Insurance Product

A. Pursuant to R.S. 22:1068, a health insurance issuer may modify its drug coverage offered to a group health plan if each of the following conditions is met.

1. The modification occurs at the time of coverage renewal.

2. The modification is approved by the commissioner. However, modification affecting drug coverage as defined in R.S. 22:1061(5)(y) and found in §14111.A of this regulation shall not require approval by the commissioner.

3. The modification is consistent with state law.

4. The modification is effective on a uniform basis among all small or large employers covered by that group health plan.

5. The health insurance issuer, on the form approved by the Department of Insurance, notifies the small or large employer group and each enrollee therein of the modification no later than the sixtieth day before the date the modification is to become effective.

6. As an exception to the requirement that a modification must occur at the time of coverage renewal, modification of drug coverage for any drug increasing over $300 per prescription or refill with an increase in the wholesale acquisition cost of at least 25 percent in the prior 365 days may occur at any time provided that 30-day notice of the modification of coverage is given. The 30-day notice of the modification of coverage shall include information on the health insurance issuer's process for an enrollee's physician to request an exception from the health insurance issuer's modification of drug coverage for purposes of continuity of care of the patient.

La. Admin. Code tit. 37, § XIII-14115

Promulgated by the Department of Insurance, Office of the Commissioner, LR 38:1028 (April 2012), Amended LR 451207 (9/1/2019), Repromulgated LR 451778 (12/1/2019), Amended LR 482298 (9/1/2022).

AUTHORITY NOTE: Promulgated in accordance with R.S.22:11, R.S. 1068(D) and R.S. 22:1074(D).