(2) HEALTH MAINTENANCE ORGANIZATIONS THAT:

(I) PROVIDE COVERAGE FOR PRESCRIPTION DRUGS UNDER
CONTRACTS THAT ARE DELIVERED OR ISSUED FOR DELIVERY IN THE STATE TO
EMPLOYERS OR INDIVIDUALS ON A GROUP OR INDIVIDUAL BASIS; AND

(II) LIMIT COVERAGE OF PRESCRIPTION DRUGS TO THOSE IN A

FORMULARY.

(C) (1) EACH ENTITY SUBJECT TO THIS SECTION SHALL ESTABLISH AND
IMPLEMENT A PROCEDURE BY WHICH A MEMBER MAY RECEIVE A PRESCRIPTION
DRUG THAT IS NOT IN A FORMULARY IF, IN THE JUDGMENT OF THE PHYSICIAN WHO
IS CARING FOR THE MEMBER, THE PRESCRIPTION DRUG IS MEDICALLY NECESSARY
BECAUSE THE FORMULARY DRUG;

(I) HAS BEEN INEFFECTIVE IN TREATING THE DISEASE OR
CONDITION OF THE MEMBER; OR

(II) HAS CAUSED OR IS LIKELY TO CAUSE AN ADVERSE REACTION
OR OTHER HARM TO THE MEMBER

(2) A MEMBER WHO OBTAINS A PRESCRIPTION DRUG UNDER THIS
SUBSECTION MAY NOT BE REQUIRED TO PAY ANY FEE OR COPAYMENT OTHER THAN
THAT REQUIRED FOR A PRESCRIPTION DRUG IN THE FORMULARY.

AN ENTITY SUBJECT TO THIS SECTION MAY NOT LIMIT THE RIGHT
OF A MEMBER WHO HAS A RECURRING DISEASE OR CONDITION TO OBTAIN A
PRESCRIPTION DRUG UNDER THIS SUBSECTION FOR TREATMENT OF THAT DISEASE
OR CONDITION.

(D) (1) AT LEAST 00 DAYS BEFORE SUBSTITUTING ANOTHER PRESCRIPTION
DRUG FOR A PRESCRIPTION DRUG IN ITS FORMULARY, AN ENTITY SUBJECT TO THIS
SECTION SHALL NOTIFY ANY MEMBER AFFECTED BY THE SUBSTITUTION, IF THE
SUBSTITUTION IS THE RESULT OF FINANCIAL INCENTIVES, INCLUDING REBATES,
OFFERED TO THE ENTITY.

(2) AN ENTITY SUBJECT TO THIS SECTION MAY NOT LIMIT OR EXCLUDE
COVERAGE FOR A PRESCRIPTION DRUG PRESCRIBED FOR A MEMBER IF:

(I) THE PRESCRIPTION DRUG WAS PRESCRIBED BY AN
AUTHORIZED PRESCRIBER FOR A DISEASE OR CONDITION OF THE MEMBER UNDER A
PRIOR HEALTH INSURANCE PLAN OF THE MEMBER'S EMPLOYER; AND

(II) AN AUTHORIZED PRESCRIBER CONTINUES TO PRESCRIBE THE
PRESCRIPTION DRUG FOR THE MEMBER FOR TREATMENT OF THAT DISEASE OR
CONDITION.

(E) (1) IF PRESCRIBED FOR A MEMBER BY AN AUTHORIZED PRESCRIBER, AN
ENTITY SUBJECT TO THIS SECTION SHALL PROVIDE COVERAGE FOR A NEW
PRESCRIPTION DRUG APPROVED BY THE FEDERAL FOOD AND DRUG
ADMINISTRATION FOR AT LEAST 1 YEAR FROM THE FIRST DAY OF SALE OF THE DRUG
AFTER APPROVAL BY THE ADMINISTRATION.