An Act Regarding Insurance and Financial Services
Maine Legislature, Session 128, LD 0696
Committee Amendment CA_A_H772 (House)

COMMITTEE AMENDMENT ,/+,, to H.P. 487, L.D. 696, Bill, "An Act 
Regarding Insurance and Financial Services" 
Amend the bill by striking out the title and substituting the following: 
'An Act To Require Notification of Adverse Changes to Prescription Drug 
Formularies in Health Plans' 
Amend the bill by striking out everything after the enacting clause and inserting the 
following: 
'PART A 
Sec. A-1. 24-A l\1RSA §4311, sub-§1, as enacted by PL 1999, c. 742, §19 and 
affected by §21, is amended to read: 
1. Formulary. If a health plan provides coverage for prescription drugs but the 
coverage limits such benefits to drugs included in a formulary, a carrier shall: 
A. 
Ensure participation of participating physicians and pharmacists in the 
development of the formulary; and 
B. Provide exceptions to the formulary limitation when a nonformulary alternative is 
medically indicated, consistent with the utilization review standards in section 4304.~ 
C. Provide an enrollee with at least 60 days' written notice of an adverse change to a 
formulary, except that a carrier may provide less than 60 days' notice when a 
prescription drug is being removed from the formulary because of concerns about 
safety. The notice must use a conspicuous font and inform the enrollee of the adverse 
change to the formulary and advise the enrollee to consult with the enrollee's provider 
about the change. 
For the purposes of this paragraph, 
11adverse change to a 
formulary
means a change that removes a drug currently prescribed for that enrollee 
from the formulary applicable to the enrollee's health plan or a change that moves the 
prescribed drug to a tier with a higher cost-sharing requirement if the carrier uses a 
formula1y with tiers; 
C10MMIT1.EE AMENDMENT 
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COMMITTEE AMENDMENT ·l)" to H.P. 487, L.D. 696 
D. If a prescription drug is removed from a fommlary, notify an enrollee affected by 
the change of the enrollee's ability to request an exception to the formulary limitation 
pursuant to paragraph B and provide a form for the enrollee to use to request an 
exception. If an enrollee has already received prior authorization for that drug, the 
carrier shall continue to honor the existing authorization until it expires, as long as the 
enrollee continues to be covered under the same health plan and the drug has not been 
removed from the formula1y because of concerns about safety; and 
E. Except when a chug has been removed because of concerns about safety, if a drug 
has been removed from a formulary and a request for an exception to a formulary 
limitation submitted by or on behalf of an enrollee is received prior to the effective 
date of the proposed change, continue to provide coverage for that drug until the 
carrier has rendered a decision on the enrollee's request for an exception to the 
formulary limitation. 
Sec. A-2. 
Application. 
The requirements of this Act apply to all policies, 
contracts and ce1tificates executed, delivered, issued for delivery, continued or renewed 
in this State on or after January 1, 2019. For purposes of this Act, all contracts are 
deemed to be renewed no later than the next yearly anniversary of the contract date. 
PARTB 
Sec. B-1. Report on formulary changes. As determined by the Department of 
Professional and Financial Regulation, Bureau of Insurance, a carrier subject to the 
requirements of the Maine Revised Statutes, Title 24~A, section 4311, subsection 1 shall 
report quarterly no less than 30 days following the end of each quarter on any changes 
made by the carrier or any pharmacy benefits manager contracted by the carrier to any 
prescription drug formulary for a health plan offered in this State betw(?en January 1, 
2019 and December 31, 2019. For purposes of this section, a change to a prescription 
ch·ug formulary includes the movement of a prescription drug to a tier with higher cost 
sharing for that drug or the removal of a prescription chug from the formulary. The report 
must be in a fo1m and manner determined by the Bureau of Insurance and include a list of 
formulary changes made by the carrier and the effective date of each formulary change; 
the prescription drugs affected by each formulary change by name and manufacturer; the 
number of enrollees affected by each formulary change; the expected impact of each 
formulary change on cost sharing for affected enrollees; a written explanation of the 
reasons for each fo1mulary change; the number of exception requests made by enrollees 
with regard to each formula1y change; and the number of exception requests granted, 
denied or withdrawn with regard to each formulary change. 
No less than 60 days 
following the end of each quaiter, as determined by the Bureau of Insurance, the bureau 
shall compile this data for those carriers required by the bureau to report and submit a 
report to the joint standing committee of the Legislature having jurisdiction over 
insurance and financial services matters. The joint standing committee of the Legislature 
having jurisdiction over insurance and financial services matters may report out 
legislation related to the report to any regular or special session of the 129th Legislature. 
Sec. B-2. 
Report on formulary changes in state employee health 
insurance program. The 3rd-party administrator or any pharmacy benefits manager 
contracted by the state employee health insurance program to administer prescription 
COMMITTE'E AMENDJ'v1ENT 
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COMMITTEE AMENDMENT"~" to H.P. 487, L.D. 696 
drug benefits for the group health plan offered to state employees and other eligible 
persons pursuant to the Maine Revised Statutes, Title 5, section 285 shall report quarterly 
no less than 30 days following the end of each quarter to the director of employee health 
and benefits within the Department of Administrative and Financial Services, Bureau of 
Human Resources on any changes made to any prescription drug formulary between 
January 1, 2019 and December 31, 2019. For purposes of this section, a change to a 
prescription drug formulary includes the movement of a prescription dmg to a tier with 
higher cost sharing for that drug or the removal of a prescription drug from the formulary. 
The report must be in a form and manner determined by the director and include a list of 
fonnulary changes made by the carrier and the effective date of each fonnulary change; 
the prescription dmgs affected by each formulary change by name and manufacturer; the 
number of enrollees affected by each fonnulary change; the expected impact of each 
formulary change on cost sharing for affected enrollees; a written explanation of the 
reasons for each formulary change; the number of exception requests made by enrollees 
with regard to each fonnulary change; and the number of exceptions granted, denied or 
withdrawn with regard to each formulary change. No less than 60 days following the end 
of each quarter, the director shall report this data to the joint standing committee of the 
Legislature having jurisdiction over insurance and financial services matters. The joint 
standing committee of the Legislature having jurisdiction over insurance and financial 
services matters may report out legislation related to any report submitted pursuant to this 
section to any regular or special session of the 129th Legislature.' 
This amendment replaces the bill. 
Part A does the following: 
SUMMARY 
1. 
It requires a carrier to provide notice of an adverse change to an enrollee's 
prescription drug formulary. At least 60 days' notice is required, except in instances in 
which a prescription drug is removed from the formulary because of concerns about 
safety. 
The amendment defines "adverse change to a fonnulary" as a change that 
removes a drug currently prescribed for that enrollee from the formulary applicable to the 
enrollee's health plan or a change that moves the prescribed drug to a tier with a higher 
cost-sharing requirement if the carrier uses a formulary with tiers. 
2. It requires a carrier to provide an enrollee with notice of the enrollee's right to 
request an exception to a f01mulary limitation when a prescription drug is removed from 
the formulary and to provide a form for an enrollee to use to make an exception request. 
3. It requires a carrier to honor any prior authorization for a drug that has been 
removed from a fotmulary until the approval expires, as long as the enrollee retains 
coverage under the same plan. 
4. It provides that when a drug is removed from a fonnulary and if an exception 
request is submitted prior to the effective date of the change, a carrier shall continue to 
provide coverage for that drng until the carrier has rendered a decision on an enrollee's 
request for an exception to the formula1y limitation. This requirement does not apply to 
drugs removed from the formulary because of concerns about safety. 
COMMITTEE AMENDMENT 
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COMMITTEE AMENDMENT «A "to H.P. 487, L.D. 696 
5. It provides that the requirements apply to all individual and group health insurance 
policies and contracts issued or renewed on or after January 1, 2019. 
Part B of the amendment requires any carrier as determined by the Department of 
Professional and Financial Regulation, Bureau of Insurance to report on any prescription 
drug formulary changes made in calendar year 2019 to the Bureau of Insurance no later 
than 30 clays following the encl of each quarter. The report must include a list of 
formulary changes made by the carrier; the prescription drugs affected by each formula1y 
change by name and manufacturer; the number of enrollees affected by each formulary 
change; the expected impact of each formulary change on the cost sharing for affected 
enrollees; the reasons for each formulary change; the number of exception requests made 
by enrollees with regard to each formulary change; and the number of exception requests 
grantee!, denied or withdrawn with regard to each formulary change. The Bureau of 
Insurance is required to compile this data for all carriers required by the bureau to report 
and submit a report to the Legislature no later than 60 days following the end of each 
quarter. 
The joint standing committee of the Legislature having jurisdiction over 
insurance and financial services matters is authorized to report out a bill to any regular or 
special session of the 129th Legislature. 
Part B also requires the state employee health insurance program to report the same 
information. 
FISCAL NOTE REQUIRED 
(See attachecl) 
COMMITTEE AMENDMENT 
Revised: 04/13/18 J'~ac 
128th JVIAINE LEGISLATURE 
LD 696 
LR 1343(02) 
An Act Regarding Insurance and Financial Services 
Fiscal Note for Bill as Amended by Committee Amendment .. n. ( H · 11 J.\ 
Committee: Insurance and Financial Services 
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Fiscal Note Required: Yes 
Fiscal Note 
Minor cost increase - All Funds 
Fiscal Detail and Notes 
Any additional costs to the State Employee Health Plan to collect and report data to the Department of Professional 
and Financial Regulation, Bureau oflnsurance, are expected to be minor and can be absorbed within existing 
budgeted resomces. 
Any additional costs to the Department of Professional and Financial Regulation to collect and repo1i data to the 
legislature are expected to be minor and can be absorbed within existing budgeted resources. 
LR1343(02) - Fiscal Note - Page 1 of 1