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North Carolina Health Insurance Requirements & Referrals

Exceptions to Drug Management Requirements

All health plans that use a closed prescription drug formulary must cover drugs that are not on the formulary, under certain circumstances:

• A plan member's physician notifies the insurance company that the formulary drug has been used to treat the patient for the condition in question; and
• The formulary drug was either ineffective in treating the condition, harmful to the patient, or is reasonably expected to be harmful to the patient and therefore, the non-formulary drug is necessary to treat the condition.

Restricted access drugs (formulary drugs that are covered only with insurance company's prior approval, or only after other specified formulary drugs have been tried without success) must also be covered on an exception basis, without prior approval or first having to try other formulary drugs, when:

• A plan member's physician certifies to the insurance company that the other formulary drug(s) has been used to treat the patient for the same condition previously; and
• The drug(s) was either ineffective or harmful to the patient and is expected to be harmful if used again.

Standing Referrals to Specialists

Managed care plans that require members to obtain a referral from their primary care physician (PCP) before seeing a specialist must allow the PCP to issue a standing referral for up to 12 months if the patient has a serious or chronic condition that is degenerative, disabling or life-threatening and ongoing specialty care is necessary.

Transitional Coverage when a Provider Leaves the Network (Continuity of Care)

Managed care plans must allow members to continue receiving coverage for treatment from providers who leave the plan's network, in order to ensure continuity of care while the member changes providers. This coverage is dependent upon specific conditions being met, including:

• The member:
• has a serious acute condition that requires treatment to avoid death or permanent harm, at the time he/she was notified that the provider was leaving the network (up to 90 days of transitional coverage is provided); or,
• has a chronic condition that is life threatening, degenerative or disabling and requires treatment over a prolonged period of time, at the time they were notified that the provider was leaving the network (up to 90 days of transitional coverage is provided); or,
• is in at least the second trimester of pregnancy, at the time he/she was notified that the provider was leaving the network (transitional coverage is provided through delivery and up to 60 days of postpartum care); or,
• is scheduled for surgery, organ transplantation or other inpatient care prior to being notified of the provider's termination (transition coverage is provided through the completion of the procedure or stay and up to 90 days of post-discharge care related to the hospital stay); or,
• is terminally ill and not expected to live longer than six months, at the time that the provider will actually leave the network (transition coverage is provided for the remainder of the member's life).
• The provider leaving the network must agree to continue treating the member, accept the plan's payment rates, and comply with other plan requirements.
• The member must, within 45 days of being notified that their provider will be leaving the network, notify the insurance company of his/her desire to take advantage of this coverage. The same rights to continuity of care described above apply when your employer changes from one health plan to another, and your provider does not participate in the new plan's network. Continuity of care requirements do not apply when you choose to change plans.

Specialists as Primary Care Provider

Managed care plans that require the use of a PCP must allow members with serious or chronic conditions that are degenerative, disabling or life-threatening and require ongoing specialty care to select a specialist to act as their PCP. This is subject to the insurance company agreeing that the specialist is capable of coordinating the patient's care, and the specialist agreeing to abide by the insurance company's procedures for PCPs.

Direct Access to Specialists

Managed care plans are required to allow female members 13 years old or older to have direct access to an OB/GYN for OB/GYN services, without a referral from a PCP. Managed care plans are required to allow all members who are under the age of 18 to select a network pediatrician as their PCP.