This bill amends the Prior Authorization Act to extend its requirements to pharmacy benefits managers (PBMs) contracted with entities under the Health Care Purchasing Act. It prohibits prior authorization for certain prescription drugs prescribed for serious mental illnesses, autoimmune disorders, cancer, rare diseases, and substance use disorders, ensuring that these medications are covered based on medical necessity determinations made by qualified healthcare professionals. Additionally, the bill limits the frequency of prior authorization for chronic maintenance drugs to once every three years, with specific exceptions.

The bill also mandates that health insurers and PBMs streamline their prior authorization processes, including the use of standardized forms and electronic systems for submissions. It establishes timelines for determinations, requiring approvals within three business days for standard requests and twenty-four hours for emergency situations. Furthermore, it outlines the penalties for non-compliance and requires annual reporting on prior authorization practices to enhance transparency and accountability in the healthcare system.

Statutes affected:
introduced version: 59A-22B-2, 59A-22B-4, 59A-22B-5, 59A-22B-8
CT substitute: 59A-22B-2, 59A-22B-4, 59A-22B-5, 59A-22B-8
PA substitute: 59A-22B-2, 59A-22B-4, 59A-22B-5, 59A-22B-8
Final Version: 59A-22B-2, 59A-22B-4, 59A-22B-5, 59A-22B-8