An Act Regarding Prior Authorizations for Prescription Drugs
Sec. 1. 24-A MRSA §4301-A, sub-§10-A, as enacted by PL 2001, c. 288, §3, is amended to read:
Sec. 2. 24-A MRSA §4301-A, sub-§13, as enacted by PL 1999, c. 742, §3, is amended to read:
Sec. 3. 24-A MRSA §4301-A, sub-§14-A is enacted to read:
Sec. 4. 24-A MRSA §4301-A, sub-§15-A is enacted to read:
Sec. 5. 24-A MRSA §4304, sub-§2, as amended by PL 2019, c. 273, §1, is further amended to read:
If a carrier does not grant or deny a request for prior authorization within the time frames required under this subsection, the request for prior authorization by the provider is granted and a carrier may not deny payment for a prescription drug dispensed by a pharmacist.
Sec. 6. 24-A MRSA §4304, sub-§2-B, as enacted by PL 2019, c. 273, §2, is amended to read:
(1) The prescription drug formulary and cost-sharing requirements under the enrollee's health plan;
(2) The prior authorization standards and requirements for the enrollee's health plan;
(3) The cost of the prescription drug requested by the provider and any alternatives to that prescription drug, as appropriate;
(4) Any information on whether there is a financial assistance program available for a prescription drug prescribed by the provider if known by the carrier; and
(5) If the provider's prior authorization request is denied, the reason for the denial and a list of any alternative prescription drugs that the carrier would approve and the cost of those alternatives.
This subsection may not be construed to interfere with an enrollee's ability to make choices related to prescription drugs. A provider shall communicate with an enrollee about the most therapeutically appropriate treatment for the enrollee's given diagnosis. When appropriate, a provider shall also provide information to an enrollee related to the cost of prescription drugs, including the cost to the enrollee if the enrollee pays out of pocket, alternative prescription drugs and prescription delivery options.
This subsection may not be construed to prohibit the right of an enrollee to choose whether to use the prescription drug coverage available through the enrollee's health plan when obtaining prescription drugs. If an enrollee chooses not to use the enrollee's health plan's prescription drug coverage for a prescription drug being prescribed by a provider, a provider has no obligation to convey this information to the carrier or pharmacy benefits manager.
Sec. 7. Bureau of Insurance to monitor compliance. Beginning January 1, 2021, the Department of Professional and Financial Regulation, Bureau of Insurance shall monitor compliance by carriers authorized to do business in this State with the requirements of the Maine Revised Statutes, Title 24-A, section 4304, subsection 2-B using its authority under Title 24-A, section 221. No later than September 30, 2021, the bureau shall submit a report to the joint standing committee of the Legislature having jurisdiction over health coverage and insurance matters on the status of compliance by carriers. If the bureau determines that a carrier is not complying with the requirements of Title 24-A, section 4304, subsection 2-B, the bureau shall take enforcement action against the carrier as appropriate. The joint standing committee of the Legislature having jurisdiction over health coverage and insurance matters may report out a bill to the Second Regular Session of the 130th Legislature based on the report.
This bill makes the following changes.
1. It adds a definition of "prior authorization" and clarifies the definitions of "medically necessary health care" and "participating provider" used in the Maine Insurance Code, chapter 56-A.
2. It sets forth additional requirements for carriers to facilitate the processing of prior authorization requests for prescription drugs by providers.