§ 23-99-1119. Medication-assisted treatment for opioid addiction
(a) Except in the case of injectables, a healthcare insurer, including Medicaid, shall not: (1) Require prior authorization in order for a patient to obtain coverage of buprenorphine, naloxone, naltrexone, methadone, and their various formulations and combinations approved by the United States Food and Drug Administration for the treatment of opioid addiction; or (2) Impose […]
§ 23-99-1117. Standardized form required for prescription drug benefits
(a) On and after January 1, 2017, to establish uniformity in the submission of prior authorization forms for prescription drugs, a utilization review entity shall utilize only a single standardized prior authorization form for obtaining approval in written or electronic form for prescription drug benefits. (b) A utilization review entity may make the form required […]
§ 23-99-1118. Rules
The State Insurance Department may promulgate rules for the implementation of this subchapter.
§ 23-99-1103. Definitions
As used in this subchapter: (1) (A) “Adverse determination” means a decision by a utilization review entity to deny, reduce, or terminate coverage for a healthcare service furnished or proposed to be furnished to a subscriber on the basis that the healthcare service is not medically necessary or is experimental or investigational in nature. (B) […]
§ 23-99-1104. Disclosure required
(a) (1) A utilization review entity shall disclose all of its prior authorization requirements and restrictions, including any written clinical criteria, in a publicly accessible manner on its website. (2) The information described in subdivision (a)(1) of this section shall be explained in detail and in clear and ordinary terms. (3) (A) Utilization review entities […]
§ 23-99-1105. Prior authorization — Nonurgent healthcare service
(a) If a utilization review entity requires prior authorization of a nonurgent healthcare service, the utilization review entity shall make an authorization or adverse determination and notify the subscriber and the subscriber’s nonurgent healthcare provider of the decision within two (2) business days of obtaining all necessary information to make the authorization or adverse determination. […]
§ 23-99-1106. Prior authorization — Urgent healthcare service
A utilization review entity shall render an expedited authorization or adverse determination concerning an urgent healthcare service and notify the subscriber and the subscriber’s healthcare provider of that expedited prior authorization or adverse determination no later than one (1) business day after receiving all information needed to complete the review of the requested urgent healthcare […]
§ 23-99-1107. Prior authorization — Emergency healthcare service
(a) A utilization review entity shall not require prior authorization for prehospital transportation or for provision of an emergency healthcare service. (b) (1) A utilization review entity shall allow a subscriber and the subscriber’s healthcare provider a minimum of twenty-four (24) hours following an emergency admission or provision of an emergency healthcare service for the […]
§ 23-99-1108. Subscribers with terminal illness — Denial of prior authorization for covered prescription pain medication prohibited
If a subscriber’s covered prescription pain medication requires a prior authorization, then the prior authorization shall not be denied if the subscriber has a terminal illness.
§ 23-99-1109. Rescission of prior authorizations — Denial of payment for prior authorized services — Limitations
(a) A decision on a request for prior authorization by a utilization review entity shall include a determination as to whether or not the individual is covered by a health benefit plan and eligible to receive the requested service under the health benefit plan. (b) (1) A utilization review entity shall not rescind, limit, condition, […]