(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.
KEY: health benefit plan insurance
Date of Last Change: August 27, 2025
Notice of Continuation: May 19, 2026
Authorizing, and Implemented or Interpreted Law: 31A-22-629; 31A-2-201; 31A-2-212