APPROVED CHAPTER
JULY 1, 2025 473
BY GOVERNOR PUBLIC LAW
STATE OF MAINE
_____
IN THE YEAR OF OUR LORD
TWO THOUSAND TWENTY-FIVE
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S.P. 460 - L.D. 1100
An Act to Clarify the Requirements for Accessing Nonformulary Drugs and
Drugs Used to Treat Serious Mental Illness
Be it enacted by the People of the State of Maine as follows:
Sec. 1. 24-A MRSA §4304, sub-§2-C, as enacted by PL 2021, c. 345, §1, is
amended to read:
2-C. Prior authorization of prescription drugs used for assessment and treatment
of serious mental illness. Notwithstanding any requirement of this section to the contrary,
a carrier shall approve a prior authorization request for medication on the carrier's
prescription drug formulary that is prescribed to assess or treat an enrollee's serious mental
illness. If a drug shortage makes a formulary drug prescribed to assess or treat an enrollee's
serious mental illness unavailable and there is no equivalent formulary drug available, the
carrier shall approve an equivalent nonformulary drug prescribed to assess and treat the
enrollee's serious mental illness for the period of time that a formulary drug is unavailable.
For the purposes of this subsection, "serious mental illness" means a mental disorder, as
defined in the most recent edition of the Diagnostic and Statistical Manual of Mental
Disorders published by the American Psychiatric Association, that results in serious
functional impairment that substantially interferes with or limits one or more major life
activities. The superintendent may adopt rules to implement this subsection. Rules adopted
pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375,
subchapter 2‑A.
Sec. 2. 24-A MRSA §4311, sub-§1-A, as corrected by RR 2023, c. 2, Pt. A, §38,
is amended to read:
1-A. Access to Request for clinically appropriate prescription drugs. For plan
years beginning on or after March 19, 2019, a carrier must allow an enrollee, the enrollee's
designee or the person who has issued a valid prescription for the enrollee to request and
gain access to a clinically appropriate drug not otherwise covered by the health plan. The
carrier's process must comply with section 4304 and with this subsection. If the carrier
approves a request under this subsection for a drug not otherwise covered by the health
plan, the carrier must treat the drug as an essential health benefit, including counting any
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cost sharing toward the plan's annual limit on cost sharing and including it when calculating
the plan's actuarial value.
A. The carrier must determine whether it will cover the drug requested and notify the
enrollee, the enrollee's designee, if applicable, and the person who has issued the valid
prescription for the enrollee of its coverage decision within 72 hours or 2 business days,
whichever is less, following receipt of the request. A carrier that grants coverage under
this paragraph must provide coverage of the drug for the duration of the prescription,
including refills.
B. The carrier must have a process by which an expedited review may be requested in
exigent circumstances. Exigent circumstances exist when an enrollee is suffering from
a health condition that may seriously jeopardize the enrollee's life, health or ability to
regain maximum function or when an enrollee is undergoing a current course of
treatment using a nonformulary drug. When an expedited review has been requested,
the carrier must determine whether it will cover the drug requested and notify the
enrollee, the enrollee's designee, if applicable, and the person who has provided a valid
prescription for the enrollee of its coverage decision within 24 hours following receipt
of the request. A carrier that grants coverage under this paragraph must provide
coverage of the drug for the duration of the exigency.
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Statutes affected:
Bill Text ACTPUB , Chapter 473: 24-A.4304, 24-A.4311