R590-261-12. Non-Formulary Drug Exception Process

(1) A carrier shall have the following exception processes that comply with 45 CFR 156.122(c) for a non-formulary drug: (a) standard exception request; (b) expedited exception request; and (c) external exception request review. (2) A carrier may require a request for an exception to be submitted with clinical documentation from the insured's health care provider. (3)(a) An external exception request review shall be reviewed by an independent review organization. (b) A carrier that fails to establish an external exception request review through an independent review organization shall comply with Section R590-261-10. (4) A granted exception shall: (a) treat the excepted drug as an essential health benefit; and (b) count any cost-sharing towards the plan's annual limitation on cost sharing.