33-21-18.1. Emergency services requirements; restrictive formulary requirements.

Every health benefits plan of every health maintenance organization shall include provisions that:

In the event a patient seeks emergency services and if necessary in the opinion of the health care provider responsible for the patient’s emergency care and treatment and warranted by his or her evaluation, such emergency provider may initiate necessary intervention necessary to stabilize the condition of the patient without seeking or receiving prospective authorization by the health maintenance organization or health benefits plan. If in the opinion of the emergency health care provider a patient’s condition has stabilized and the emergency health care provider certifies that the patient can be transported to another facility without suffering detrimental consequences or aggravating the patient’s condition, the patient may be relocated to another facility which will provide continued care and treatment as necessary; and#

When a health maintenance organization uses a restrictive formulary for prescription drugs, such use shall include a written procedure whereby patients can obtain, without penalty and in a timely fashion, specific drugs and medications not included in the formulary when:#

1. (A)

   The formulary’s equivalent has been ineffective in the treatment of the patient’s disease or condition; or#

2. (B)

   The formulary’s drug causes or is reasonably expected to cause adverse or harmful reactions in the patient.#