Nev. Admin. Code § 695C.175 - Health maintenance organization: Removal of prescription drug from approved formulary prohibited; exception; movement to different tier in formulary; addition of drug to formulary

1. Except as otherwise provided in this section, a health maintenance organization that offers a health benefit plan in the individual market which provides coverage for prescription drugs and uses a formulary that has been approved by the Commissioner pursuant to NRS 687B.120 shall not:

(a) Remove a prescription drug from the formulary; or

(b) If the formulary includes two or more tiers of benefits providing for different deductibles, copayments or coinsurance applicable to the prescription drugs in each tier, move a drug to a tier with a larger deductible, copayment or coinsurance, during the plan year for which the formulary was approved by the Commissioner.

2. A health maintenance organization described in subsection 1 may:

(a) Remove a prescription drug from a formulary at any time if:

(1) The drug is not approved by the United States Food and Drug Administration;

(2) The United States Food and Drug Administration issues a notice, guidance, warning, announcement or any other statement about the drug which calls into question the clinical safety of the drug; or

(3) The prescription drug is approved by the United States Food and Drug Administration for use without a prescription.

(b) If the health maintenance organization's formulary includes two or more tiers of benefits providing for different deductibles, copayments or coinsurance applicable to the prescription drugs in each tier, move a brand name prescription drug to a tier with a larger deductible, copayment or coinsurance if the health maintenance organization adds to the formulary a generic prescription drug that is approved by the United States Food and Drug Administration for use as an alternative to the brand name prescription drug at:

(1) The benefit tier from which the brand name prescription drug is being moved; or

(2) A benefit tier that has a smaller deductible, copayment or coinsurance than the benefit tier from which the brand name prescription drug is being moved.

3. This section does not prohibit a health maintenance organization from adding a prescription drug to a formulary at any time.

4. This section does not apply to a grandfathered plan.

5. As used in this section, "health benefit plan" has the meaning ascribed to it in NRS 687B.470.

Notes

Nev. Admin. Code § 695C.175

Added to NAC by Comm'r of Insurance by R074-14, eff. 1/1/2016

NRS 679B.130, 687B.120