(a) Every insurer that delivers or issues for delivery in this state an accident and health insurance policy that provides hospital, surgical, or medical expense coverage and also provides coverage for medication for the detoxification or maintenance treatment of a substance use disorder shall include in the policy processes that allow an insured, the insured’s designee, or the insured’s prescribing physician (or other prescriber, as appropriate) to request a formulary exception and gain access to clinically appropriate medication for the detoxification or maintenance treatment of a substance use disorder not otherwise covered by the policy (a request for formulary exception). With respect to the process for such a formulary exception, an insurer shall follow the process and procedures specified in Insurance Law article 49 or Public Health Law article 49, as applicable, except as otherwise provided in this section.

An insurer that denies an exception request under subdivision (b) or (c) of this section shall provide written notice of its determination to the insured or the insured’s designee and the prescribing physician (or other prescriber, as appropriate). The written notice shall be considered a final adverse determination under Insurance Law section 4904 or Public Health Law section 4904, as applicable. Written notice shall also include the name or names of clinically appropriate medications for the detoxification or maintenance treatment of a substance use disorder covered by the insurer to treat the insured.