<html> <head> <title>Rule 20:06:56:08 Prescription drug benefits.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:56:08"> <META NAME="Description" Content="Administrative Rules 20:06:56:08 Prescription drug benefits."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; text-align:justify; font-size:12.0pt; font-family:"Times New Roman","serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>20:06:56:08.&nbsp;&nbsp;Prescription drug benefits.</b> A health plan does not provide essential health benefits unless it covers at least the greater of:</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;One drug in every United States Pharmacopeia (USP) category and class; or</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;The same number of prescription drugs in each category and class as the essential health benefits benchmark.</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The plan is required to submit its drug list to the director. A health plan does not fail to provide essential health benefits for prescription drug solely because it does not offer drugs for services prohibited under SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17-147">58-17-147.</A> A health plan providing essential health benefits as defined in §&nbsp;20:06:56:03 must have procedures in place that allow an enrollee to request clinically appropriate drugs not covered by the health plan. Such procedures must include a process for an enrollee, the enrollee's designee, or the enrollee's prescribing physician or other prescriber to request an expedited review based on exigent circumstances.</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Exigent circumstances 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.</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; A health plan must make its coverage determination on an expedited review request based on exigent circumstances and notify the enrollee or the enrollee's designee and the prescribing physician or other prescriber, as appropriate of its coverage determination no later than 24 hours after it receives the request.</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; A health plan that grants an exception based on exigent circumstances must provide coverage of the non-formulary drug for the duration of the exigency.</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 39 SDR 203, effective June 10, 2013; 41 SDR 93, effective December 3, 2014.</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17-87">58-17-87</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-79">58-18-79.</A></p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-17-87">58-17-87</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-79">58-18-79</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=58-18-80">58-18-80.</A></p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Reference:</b> United States Pharmacopeia (USP).</p> <p class=MsoNormal style='margin-left:-.7pt'>&nbsp;</p> </div> </body> </html>