An Act Regarding Prior Authorizations for Prescription Drugs
Maine Legislature, Session 130, LD 0523
Committee: Health Coverage, Insurance and Financial Services
Sponsors: CLAXTON, BROOKS
Amends: 24-A MRSA §4304

Legislative Document
No. 523
S.P. 207
In Senate, February 24, 2021
An Act Regarding Prior Authorizations for Prescription Drugs
Received by the Secretary of the Senate on February 22, 2021.  Referred to the Committee 
on Health Coverage, Insurance and Financial Services pursuant to Joint Rule 308.2 and ordered 
printed.
DAREK M. GRANT
Secretary of the Senate
Presented by Senator CLAXTON of Androscoggin.
Cosponsored by Representative BROOKS of Lewiston.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  24-A MRSA §4304, sub-§2, ¶D, as enacted by PL 2019, c. 273, §1, is 
amended to read:
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.
Sec. 2.  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 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, 2023, unless a waiver is granted by the superintendent, a 
carrier or entity under contract to a carrier shall make available to a provider in real 
time at the point of prescribing one or more electronic benefit tools that are capable of 
integrating with at least one electronic prescribing system or electronic medical record 
system to provide complete, accurate, timely, clinically appropriate formulary and 
benefit information specific to an enrollee, including, but not limited to, enrollee cost-
sharing information, information on any available formulary alternatives that are 
clinically appropriate and information about the formulary status and the utilization 
review and prior authorization requirements of each drug presented.  Upon a carrier's 
request, the superintendent may grant a waiver from the requirements of this paragraph 
based on a demonstration of good cause.
Sec. 3.  Bureau of Insurance to monitor compliance.  Beginning January 1, 
2022, 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.  The bureau shall also request information from carriers on 
the adoption and usage of electronic transmission by health care providers for requesting 
prior authorization for prescription drugs from carriers.  No later than June 1, 2023, 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 131st Legislature based on the report.
SUMMARY
This bill does the following.
1.  It requires carriers to provide by January 1, 2023 at least one electronic tool to 
facilitate the availability of certain prescription drug benefit information in real time at the 
point of prescribing and when submitting prior authorization requests for prescription 
drugs. It also permits the Superintendent of Insurance to grant a waiver from the 
requirements for good cause.
2.  It requires the Department of Professional and Financial Regulation, Bureau of 
Insurance to monitor compliance by carriers with the requirements of law related to 
electronic transmission of prior authorization requests for prescription drugs and to submit 
a report to the joint standing committee of the Legislature having jurisdiction over health 
coverage and insurance matters on the status of that compliance by June 1, 2023.