An Act Regarding Prior Authorizations for Prescription Drugs
Maine Legislature, Session 129, LD 2106
Committee: Health Coverage, Insurance and Financial Services
Sponsors: GRATWICK, HYMANSON, CLAXTON, DILL, DOW, MOORE, BRENNAN, MEYER, TEPLER
Amends: 24-A MRSA §4301-A, 24-A MRSA §4304

Legislative Document
No. 2106
S.P. 752
In Senate, February 13, 2020
An Act Regarding Prior Authorizations for Prescription Drugs
Approved for introduction by a majority of the Legislative Council pursuant to Joint Rule 
203.
Reference to the Committee on Health Coverage, Insurance and Financial Services 
suggested and ordered printed.
DAREK M. GRANT
Secretary of the Senate
Presented by Senator GRATWICK of Penobscot.
Cosponsored by Representative HYMANSON of York and
Senators: CLAXTON of Androscoggin, DILL of Penobscot, DOW of Lincoln, MOORE of 
Washington, SANBORN, L. of Cumberland, Representatives: BRENNAN of Portland, 
MEYER of Eliot, TEPLER of Topsham.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  24-A MRSA §4301-A, sub-§10-A, as enacted by PL 2001, c. 288, §3, is 
amended to read:
10-A.  Medically necessary health care.  "Medically necessary health care" means 
health care services or products provided to an enrollee for the purpose of preventing, 
diagnosing or treating an illness, injury or disease or the symptoms of an illness, injury or 
disease in a manner that is:
A.  Consistent Evidence-based and consistent with generally accepted standards of 
medical practice;
B.  Clinically appropriate in terms of type, frequency, extent, site and duration;
C.  Demonstrated through scientific evidence in peer-reviewed medical literature to 
be effective in improving health outcomes;
D.  Representative of "best practices" in the medical profession; and
E.  Not primarily for the convenience of the enrollee or physician or other health care 
practitioner.; and
F.  With respect to pharmacy services, not primarily based on the cost of a 
medication.
Sec. 2.  24-A MRSA §4301-A, sub-§13, as enacted by PL 1999, c. 742, §3, is 
amended to read:
13.  Participating provider.  "Participating provider" means a licensed or certified 
provider of health care services, including mental health services and pharmacy services, 
or health care supplies that has entered into an agreement with a carrier to provide those 
services or supplies to an individual enrolled in a managed care plan.
Sec. 3.  24-A MRSA §4301-A, sub-§14-A is enacted to read:
14-A.  Pharmacy benefits manager.  "Pharmacy benefits manager" has the same 
meaning as in section 4347, subsection 17.
Sec. 4.  24-A MRSA §4301-A, sub-§15-A is enacted to read:
15-A.  Prior authorization.  "Prior authorization" means a utilization review process 
used by a carrier:
A.  As an educational tool to ensure that enrollees and providers have the most 
appropriate evidence-based health care options for diagnosis and treatment of the 
enrollees' medical conditions; and
B.  To determine if the carrier will cover a prescribed procedure, medication, service, 
treatment or laboratory or diagnostic test, prescribed durable medical equipment or a 
prescribed prosthetic device based on medical necessity, the availability of generic 
alternatives or the potential for drug interactions.
Sec. 5.  24-A MRSA §4304, sub-§2, as amended by PL 2019, c. 273, §1, is 
further amended to read:
2.  Prior authorization of nonemergency services.  Except for a request in exigent 
circumstances as described in section 4311, subsection 1-A, paragraph B, a request by a 
provider for prior authorization of a nonemergency service must be answered by a carrier 
within 72 hours or 2 business days, whichever is less, in accordance with this subsection.
A.  Both the provider and the enrollee on whose behalf the authorization was 
requested must be notified by the carrier of its determination.
B.  If the carrier responds to a request by a provider for prior authorization with a 
request for additional information, the carrier shall make a decision within 72 hours 
or 2 business days, whichever is less, after receiving the requested information.
C.  If the carrier responds that outside consultation is necessary before making a 
decision, the carrier shall make a decision within 72 hours or 2 business days, 
whichever is less, from the time of the carrier's initial response.
D.  The prior authorization standards used by a carrier must be clear and readily 
available to enrollees, participating providers, pharmacists and other providers.  With 
regard to prior authorization for prescription drugs, a carrier shall comply with the 
requirements set forth in subsection 2-B.  A provider must make best efforts to 
provide all information necessary to evaluate a request, and the carrier must make 
best efforts to limit requests for additional information.
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:
2-B.  Electronic transmission of prior authorization requests.  Beginning no later 
than January 1, 2020, if a health plan provides coverage for prescription drugs, the carrier 
must accept and respond to prior authorization requests in accordance with subsection 2 
and this subsection through a secure electronic transmission using standards 
recommended by a national institute for the development of fair standards and adopted by 
a national council for prescription drug programs for electronic prescribing transactions. 
For the purposes of this subsection, transmission of a facsimile through a proprietary 
payer portal or by use of an electronic form is not considered electronic transmission.  A 
carrier's electronic transmission system for prior authorization requests for prescription 
drugs must comply with the following.
A.  No later than January 1, 2021, a carrier or entity under contract to a carrier shall 
make available to a provider in real time at the point of prescribing and at the point of 
dispensing the following information related to each enrollee:
(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.
B.  The process of accepting and responding to prior authorization requests in real 
time must be facilitated by a carrier with other carriers, pharmacy benefits managers, 
health systems, providers, pharmacies and other 3rd parties, including, but not limited 
to, intermediaries, real-time networks, switches and translation services.  To expedite 
the implementation and adoption of real-time electronic transmission, any such entity 
must be capable of supporting and using standards recommended by a national 
institute for the development of fair standards and adopted by a national council for 
prescription drug programs for electronic prescribing transactions.  Any additional 
cost to a carrier may not be passed on to an enrollee as a component of the premium.
C.  Prescription cost information must be transparent and displayed to a provider at 
the point of prescribing and must include any options available to the enrollee, 
including the cost of a prescription drug at the enrollee's pharmacy of choice, the cost 
of mail order when available, any costs for using a specialty pharmacy if applicable 
and the cost to the enrollee if the enrollee pays out of pocket.
D.  A carrier or a pharmacy benefits manager may not prohibit the display of cost, 
benefit and coverage information at the point of prescribing that reflects other 
choices, such as the cost to the enrollee if the enrollee pays out of pocket, financial 
assistance and support programs if known to the carrier and the cost of a prescription 
drug at the enrollee's pharmacy of choice.
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 
SUMMARY
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.