On August 7, 2025, the Utah Department of Insurance (DOI) finalized changes to R590-261 Health Benefit Plan Adverse Benefit Determinations. The changes introduce a new section that specifies that a carrier must provide an exception process for non-formulary drugs that comply with the federal law outlined in 45 CFR 156.122. That federal section requires a process for an enrollee, designee, or prescribing provider to request review of, and access to, a clinically appropriate drug not included on a carrier's covered formulary drug list.
If an exception request is granted, the carrier must treat the excepted drugs as an essential health benefit, including counting any cost-sharing towards the plan's annual limitation. The rule change also updates a link to the department's website, where consumers can find information about independent reviews.
Employers with plans governed by state laws should be aware of these mandates and can contact their carrier for further details.
Find more details on the mandate updates here: R590-261 Health Benefit Plan Adverse Benefit Determinations