SP0329, LD 984, item 1, An Act To Amend the Health Plan Improvement Law Regarding Prescription Drug Step Therapy and Prior Authorization

An Act To Amend the Health Plan Improvement Law Regarding Prescription Drug Step Therapy and Prior Authorization

Be it enacted by the People of the State of Maine as follows:

Sec. 1. 24-A MRSA §4304, sub-§1-A is enacted to read:

1-A. Prescription drug step therapy. The clinical review criteria used by a carrier in approving prescription drugs:

A. Must adhere to federal Food and Drug Administration prescription drug labeling; and

B. May not require failure on the same medication on more than one occasion for patients continuously enrolled in a health plan offered by the carrier.

Nothing in this subsection may be construed to prevent a health care practitioner from prescribing a medication for an off-label use or from prescribing a medication on more than one occasion when the health care practitioner determines it is medically appropriate.

A carrier that requires failure on one or more drugs as a condition of prior authorization for a nonpreferred drug may not collect a copayment greater than the lowest cost preferred drug copayment in the same drug class from an enrollee having satisfied the prior authorization requirements, as judged by the prescribing health care practitioner. Nothing in this subsection may be construed to prevent a carrier from collecting tiered copayments from enrollees not subject to the prior authorization requirements set forth in this subsection.

Sec. 2. 24-A MRSA §4304, sub-§2, as amended by PL 1999, c. 742, §12, is further amended to read:

2. Prior authorization of nonemergency services. Requests by a provider for prior authorization of a nonemergency service must be answered by a carrier within 2 business days 24 hours by telephone or other telephonic or electronic communications device. Both the provider and the enrollee on whose behalf the authorization was requested must be notified by the carrier of its determination. If the information submitted is insufficient to make a decision, the carrier shall notify the provider within 2 business days 24 hours by telephone or other telephonic or electronic communications device of the additional information necessary to render a decision. If the carrier determines that outside consultation is necessary, the carrier shall notify the provider and the enrollee for whom the service was requested within 2 business days 24 hours by telephone or other telephonic or electronic communications device. The carrier shall make a good faith estimate of when the final determination will be made and contact the enrollee and the provider as soon as practicable. Notification requirements under this subsection are satisfied by written notification postmarked within the time limit specified. If a carrier fails to respond within 24 hours after receiving a completed prior authorization request from a health care practitioner, the prior authorization request is deemed to have been granted.

SUMMARY

This bill establishes certain standards for prescription drug step therapy policies. The bill also reduces the time for health insurance carriers to respond to nonemergency prescription drug prior authorization requests from 2 days to 24 hours.

SP0329 LD 984	Session - 126th Maine Legislature		LR 1601 Item 1
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