11 CRR-NY 52.74NY-CRR
STATE COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK
TITLE 11. INSURANCE
CHAPTER III. POLICY AND CERTIFICATE PROVISIONS
SUBCHAPTER A. LIFE, ACCIDENT AND HEALTH INSURANCE
PART 52. MINIMUM STANDARDS FOR FORM, CONTENT AND SALE OF HEALTH INSURANCE, INCLUDING STANDARDS OF FULL AND FAIR DISCLOSURE
11 CRR-NY 52.74
11 CRR-NY 52.74
52.74 Coverage of contraceptive drugs, devices, or products.
(a) Pursuant to Insurance Law sections 3216(i)(17)(E), 3221(l)(16) and 4303(cc), every policy that provides medical, major medical, or similar comprehensive type coverage shall provide coverage for all FDA-approved contraceptive drugs, devices, and other products. Where the FDA has approved one or more therapeutic and pharmaceutical equivalent, as defined by the FDA, versions of a contraceptive drug, device, or product, an insurer shall not be required to include all such therapeutic and pharmaceutical equivalent versions in its formulary, as long as at least one is included and covered without cost-sharing. If the covered contraceptive drug, device, or product is not available or is deemed medically inadvisable, an insurer shall provide coverage for an alternate therapeutic and pharmaceutical equivalent version of the contraceptive drug, device, or product without cost-sharing.
(b)
(1) Pursuant to Insurance Law sections 3216(i)(17)(E), 3221(l)(16) and 4303(cc), an insured, an insured’s designee, or an insured’s health care provider may submit a request to an insurer for coverage of a non-covered contraceptive drug, device, or product. Such request shall indicate whether the covered contraceptive drug, device, or product is not available or is medically inadvisable for the insured. An insurer may require that the request for coverage be in writing. The insurer shall use the exception form promulgated by the superintendent if the insurer requires a written request.
(2) If the attending health care provider, in his or her reasonable professional judgment, determines that the use of a specific non-covered therapeutic or pharmaceutical equivalent of a drug, device, or product is warranted, the health care provider’s determination shall be final.
(3)
(i) The insurer shall provide coverage of the non-covered contraceptive drug, device, or product within 72 hours of receipt of a standard request not based on exigent circumstances. The insurer shall provide coverage of the non-covered contraceptive drug, device, or product within 24 hours of receipt of an expedited request based on exigent circumstances. In both situations, the insurer shall provide such coverage without cost-sharing.
(ii) For purposes of this paragraph, exigent circumstances means a circumstance under which an insured is suffering from a health condition that may seriously jeopardize the insured’s life, health, or ability to regain maximum function or is undergoing a current course of treatment using a non-covered contraceptive drug, device, or product.
11 CRR-NY 52.74
Current through July 31, 2021
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