An Act To Amend the Health Plan Improvement Law Regarding Prescription Drug Step Therapy and Prior Authorization
Maine Legislature, Session 126, LD 0984
Committee: Insurance and Financial Services
Sponsors: GRATWICK, MORRISON, CRAVEN, LACHOWICZ, PATRICK, EVANGELOS, JONES, KUSIAK, NADEAU, SAUCIER
Amends: 24-A MRSA §4304

Legislative Document 
No. 984 
S.P. 329 
In Senate, March 12, 2013 
An Act To Amend the Health Plan Improvement Law Regarding 
Prescription Drug Step Therapy and Prior Authorization 
Reference to the Committee on Insurance and Financial Services suggested and ordered 
printed. 
DAREK M. GRANT 
Secretary of the Senate 
Presented by Senator GRATWICK of Penobscot. 
Cosponsored by Representative MORRISON of South Portland and 
Senators: CRAVEN of Androscoggin, LACHOWICZ of Kennebec, PATRICK of Oxford, 
Representatives: EVANGELOS of Friendship, JONES of Freedom, KUSIAK of Fairfield, 
NADEAU of Winslow, SAUCIER of Presque Isle. 
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.