Re: Pago de Primas, Manejo de Despacho de Medicamentos, Proveedores Fuera de la Red, Preautorizaciones, Referidos y Reclamaciones de Proveedores, Asegurados y Suscriptores.

E d i f i c i o W o r l d P l a z a 2 6 8 A v e . M u ñ o z R i v e r a  S a n J u a n , P R 0 0 9 1 8  T e l . 7 8 7 . 3 0 4 . 8 6 8 6 F a x 7 8 7 . 2 7 3 . 6 0 8 2 w w w . o c s . p r . g o v GOVERNMENT OF PUERTO RICO Office of the Commissioner of Insurance January 8, 2020 RULING LETTER NO. CN-2020-254-D TO ALL HEALTH INSURANCE ORGANIZATIONS OR INSURERS THAT WRITE HEALTH INSURANCE IN PUERTO RICO, THEIR PHARMACY BENEFITS ADMINISTRATORS, UTILIZATION REVIEW ORGANIZATIONS, AND OTHER AGENTS OR THIRD-PARTY ADMINISTRATORS RE: PAYMENT OF PREMIUMS, MANAGEMENT OF DISPENSING OF MEDICATION, OUT OF NETWORK PROVIDERS, PREAUTHORIZATIONS, REFERRALS, AND CLAIMS BY PROVIDERS, INSUREDS, AND SUBSCRIBERS On January 7, 2020 the Governor of Puerto Rico, the Honorable Wanda Vázquez-Garced, issued Executive Order OE-2020-001, decreeing a state of emergency due to the earthquakes that have occurred in Puerto Rico. Pursuant to this executive order, and under the powers and functions vested in the Commissioner of Insurance in the provisions of the Insurance 2.030 of the Insurance Code, we are issuing the following guidelines: Grace Period for Payment of Premiums – Health insurance organizations or insurers that write health insurance shall provide a grace period of at least thirty (30) days for the payment of premiums. This ruling does not imply a waiver of payment of the premium. Likewise, in the case of premiums that are paid through direct deposit or a checking account penalties for insufficient funds will also be waived. This does not prevent any voluntary payment agreement with the insureds and subscribers. Dispensing of medication - Health insurance organizations or insurers that write health insurance with pharmacy coverage shall suspend any requirement used to manage the dispensing of medication, (excluding controlled medication), services, and/or medical treatment included in the pharmacy coverage or health services benefits to which the covered individual or insured has a right under the health insurance policy. This includes the suspension of waiting periods for obtaining refills, suspension of requirements for dispensing medication for extended periods, suspension of preauthorization requirements for medications, sliding scale therapy requirements, limitation requirements by medical specialty, and limitation requirements for the amount of medications, among others. The insurer or the PBM, as the case may be, are advised that they will be liable for payment of claims submitted by a pharmacist or a licensed medical device provider for the payment or reimbursement of medication that is dispensed under a prescription refill, or for the device, for the duration of the emergency, as provided in Act No. 274-2018. 2 Out of network providers – Health insurance organizations or insurers that write health insurance must allow access to health services through non-participating or non-contracted providers, without applying penalties or restrictions. A claim will be subject to processing for payment when it is for a service rendered by a provider, “whether or not a participating provider” of the insurer or health insurance organization, for health care services (including physical and mental conditions), whether or not they are emergency services, provided they are covered by the health insurance of the covered individual or insured and that after rendering the service the provider submits the information required by the insurer or health insurance organization for processing the payment of the claim. The review for determining whether the information in the clinical record of the provider making the claim corresponds to the health care services that are shown in the claim shall be retrospective, that is to say, after the health care service was provided. Preauthorizations and referrals - Health insurance organizations or insurers that write health insurance must suspend the requirements for preauthorizations, referrals, or medical necessity reviews. This includes all health services in the coverage, including medical equipment. Term for filing claims –Health insurance organizations or insurers that write health insurance shall extend the applicable terms for providers to submit claims for payment for health services provided or received. The guidelines established herein will be in effect from the date on which the state of emergency was decreed on January 7, 2020, until the date on which the state of emergency ends or the Commissioner of Insurance suspends the effect of the Letter, whichever occurs first. Strict compliance with these guidelines is hereby required. Failure to comply with such will entail the application of severe sanctions. Very truly yours, Javier Rivera-Ríos Commissioner of Insurance