SUBPART B-1. COVERAGE OF PRESCRIPTION DRUGS

THROUGH A DRUG FORMULARY

§1060.1. Definitions

As used in this Subpart, the following definitions shall apply:

(1) "Authorized prescriber" means a person licensed, registered, or otherwise authorized by the appropriate licensing board to prescribe prescription drugs in the course of professional practice.

(2) "Drug formulary" or "formulary" means a list of prescription drugs which meets any of the following criteria:

(a) For which a health benefit plan provides coverage.

(b) For which a health benefit plan approves payment.

(c) That a health insurance issuer encourages or offers incentives for physicians or other authorized prescribers to prescribe.

(3) "Enrollee" or "insured" means an individual who is enrolled or insured by a health insurance issuer under a health benefit plan.

(4) "Health benefit plan" or "plan" means an entity which provides benefits through or by a health insurance issuer consisting of health care services provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as health care services under any hospital or medical service policy or certificate, hospital or medical service plan contract, preferred provider organization agreement, or health maintenance organization contract; however, "health benefit plan" shall not include benefits due under Chapter 10 of Title 23 of the Louisiana Revised Statutes of 1950 or limited benefit and supplemental health insurance policies, benefits provided under a separate policy, certificate, or contract of insurance for accidents, disability income, limited scope dental or vision benefits, benefits for long-term care, nursing home care, home health care, or specific diseases or illnesses, or any other limited benefit policy or contract as defined in R.S. 22:47(2)(c).

(5) "Health care services" means services, items, supplies, or prescription drugs for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease.

(6) "Health insurance issuer" or "issuer" means any entity that offers a health benefit plan through a policy, contract, or certificate of insurance subject to state law that regulates the business of insurance. For purposes of this Subpart, a "health insurance issuer" or "issuer" shall include but not be limited to a health maintenance organization as defined and licensed pursuant to Subpart I of Part I of Chapter 2 of this Title. A "health insurance issuer" or "issuer" shall not include any entity preempted as an employee benefit plan under the Employee Retirement Income Security Act of 1974 or the Office of Group Benefits.

(7) "Physician" means a person licensed by the Louisiana State Board of Medical Examiners.

(8) "Prescription drug" or "drug" means any of the following:

(a) A substance for which federal or state law requires a prescription before the substance may be legally dispensed to the public.

(b) A drug or device that under federal law is required, before being dispensed or delivered, to be labeled with the statement: "Caution: Federal law prohibits dispensing without prescription" or "Rx only" or another legend that complies with federal law.

(c) A drug or device that is required by federal or state statute or regulation to be dispensed on prescriptions or that is restricted to use by a physician or other authorized prescriber.

Acts 2011, No. 350, §1, eff. Jan. 1, 2012.