Feb. 5, 2015

Legislative Update: Expedited Formulary Exception Process for Urgent Circumstances

On May 27, 2014, the Department of Health and Human Services issued a final regulation entitled, Patient Protection and Affordable Care Act; Exchange and Insurance Market Standards for 2015 and Beyond.

Beginning with coverage years on or after Jan. 1, 2015, issuers providing essential health benefits must provide consumers with an expedited formulary exception process for urgent circumstances that exist when:

• An enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function
• Or when an enrollee is undergoing a current course of treatment using a non-formulary drug

After receiving a request from an enrollee or the prescribing physician, a health plan issuer must make its coverage determination on these expedited reviews, and notify the enrollee or the prescribing physician of its coverage determination no later than 24 hours after it receives the request. A health plan that grants an exception based on urgent circumstances must provide coverage of the non-formulary drug for the duration of the exigency.

For additional information, we encourage you to refer to the final rule.

Blue Cross and Blue Shield of Oklahoma is committed to achieving full compliance by reviewing and responding to formulary exception requests for Qualified Health Plan members within the timeframes according to the law.

The information provided above is only intended to be a brief summary of legislation that has been proposed or laws that have been enacted and is not an exhaustive description of the law or a legal opinion of such law. This material is for informational purposes only and is not legal advice. If you have any questions regarding this legislation, you should consult with your legal advisor.