This bill amends the Prior Authorization Act to extend its requirements to pharmacy benefits managers (PBMs) and introduces specific provisions regarding prior authorization for prescription drugs. Notably, it prohibits prior authorization for certain medications prescribed to treat serious mental illnesses, autoimmune disorders, cancer, rare diseases, and substance use disorders, unless a biosimilar or generic version is available. Additionally, the bill mandates that once prior authorization is granted for chronic maintenance drugs, it cannot be required again for three years, except under specific circumstances such as fraud or significant regulatory changes.

The bill also enhances the oversight and reporting responsibilities of the office of superintendent of insurance, requiring it to maintain logs of complaints against health insurers and PBMs, and to provide annual reports detailing prior authorization data and compliance issues. Furthermore, it establishes that health insurers and PBMs must streamline their prior authorization processes, including the use of electronic systems for submissions and tracking, and ensures that determinations are made promptly to avoid jeopardizing patients' health.

Statutes affected:
introduced version: 59A-22B-2, 59A-22B-4, 59A-22B-5, 59A-22B-8