Health Carrier Prescription Drug Benefit Management Model Act

What this document is

Health Carrier Prescription Drug Benefit Management Model Act is a naic model law published by National Association of Insurance Commissioners (NAIC). It is one of the documents that insurance license exam questions are written from, including life & health practice questions. This page summarizes it and points to the official version, which is the text to rely on.

Sections cited in practice questions

Each practice answer shows the exact passage it comes from. These are sections of this document that questions cite, with a short excerpt from the source text.

• NAIC Model NAIC 022: Section 5F(1) (Pharmacy Access)

  “A health carrier shall allow covered persons to access outpatient prescription drug benefits at in-network retail or mail order pharmacies, unless: (a) The drug is subject to restricted distribution by the FDA; or (b) The drug requires special handling, provider coordination or patient education...”

• NAIC Model NAIC 022: Section 6A(2)(c) (Formulary Notice)

  “The prescription drug benefit information shall include a notice for any individual reviewing the information that the inclusion of a prescription drug on a health benefit plan’s formulary does not mean that a prescriber will prescribe that drug for the individual’s specific medical condition.”

• NAIC Health Carrier Prescription Drug Benefit Management Model Act § 10.B (responsibility for contracted persons)

  “B. Whenever a health carrier contracts with another person to perform activities required under this Act or applicable regulations, the commissioner shall hold the health carrier responsible for monitoring the activities of that person with which the health carrier contracts and for ensuring that...”

• NAIC Health Carrier Prescription Drug Benefit Management Model Act § 6.B (notice of change to prescribers and network pharmacies)

  “B. Whenever the health carrier makes or approves a change in a formulary that causes a particular prescription drug not to be covered, applies a new or revised dose restriction that causes a prescription for a particular prescription drug not to be covered for the number of doses prescribed, or...”

• NAIC Health Carrier Prescription Drug Benefit Management Model Act § 7.D(2)(a) (consequence of a late decision)

  “(2) (a) If the health carrier fails to make a decision on the request and provide notice of the decision within the time frame required under Paragraph (1)(a) or Paragraph (1)(b): (i) The covered person shall be entitled to have coverage for, up to one month’s supply of the prescription drug that...”

• NAIC Health Carrier Prescription Drug Benefit Management Model Act § 5.C (minimum formulary breadth)

  “C. Each health carrier that offers coverage for prescription drugs shall ensure that it offers a formulary based on the recommendations of the carrier’s P&T committee and covers at least the greater of: (1) One drug in every United States Pharmacopeia (USP) category and class; or (2) The same...”

• NAIC Health Carrier Prescription Drug Benefit Management Model Act § 5.D(2) (rare and ultra-rare disease review)

  “(2) In the case of rare or ultra-rare diseases, the P&T committee process under Paragraph (1) shall include the review, as the P&T committee considers appropriate and necessary, of clinically appropriate and relevant information when there is no or limited medical and scientific evidence concerning...”

• NAIC Health Carrier Prescription Drug Benefit Management Model Act § 5.B(3) (P&T committee conflict of interest policies)

  “(3) The health carrier shall ensure that any P&T committee established under Subsection A has the following policies and disclosure requirements in place that address potential conflicts of interest that members of a P&T committee may have with the carrier and any pharmaceutical developer or...”

• NAIC Health Carrier Prescription Drug Benefit Management Model Act § 9.A(2) (record retention period)

  “(2) The records shall be maintained for period of three (3) years or until the completion of the health carrier’s next market conduct examination, whichever is later, and shall be made available to the commissioner upon request by the commissioner.”

• Health Carrier Prescription Drug Benefit Management Model Act, Section 5B(1) (P&T committee membership)

  “B. (1) Any P&T committee established under Subsection A shall include members the health carrier considers appropriate who represent a sufficient number of clinical specialties to adequately meet the needs of covered persons, the majority of which are practicing physicians, practicing pharmacists...”

• Health Carrier Prescription Drug Benefit Management Model Act, Section 7B(1) (medical exceptions request, prescriber determination)

  “B. (1) A covered person or the covered person’s authorized representative may file, and the health carrier shall review, a request under Subsection A only if the covered person’s prescribing provider has determined that the requested prescription drug is medically necessary to treat the covered...”

• Health Carrier Prescription Drug Benefit Management Model Act, Section 7F(2) (contents of a denial)

  “(2) The denial shall, in plain language, set forth: (a) The specific reason or reasons for the denial; (b) A reference to the evidence or documentation, including the clinical review criteria, including practice guidelines, and clinical evidence and medical and scientific evidence considered in...”

Practice this material

Questions about this source

More NAIC model laws sources

• INDIVIDUAL MARKET HEALTH INSURANCE COVERAGE MODEL REGULATIONNAIC model law
• INDIVIDUAL MARKET HEALTH INSURANCE COVERAGE MODEL ACTNAIC model law
• Advertisements of Accident and Sickness Insurance Model RegulationNAIC model law
• Health Information Privacy Model ActNAIC model law
• Health Benefit Plan Network Access and Adequacy Model ActNAIC model law
• Health Carrier External Review Model ActNAIC model law
• MODEL HEALTH PLAN FOR UNINSURABLE INDIVIDUALS ACTNAIC model law
• STOP LOSS INSURANCE MODEL ACTNAIC model law