SB 98

Abstract

Health insurance; prior authorization. Requires that any provider contract between a carrier and a participating health care provider contain specific provisions that require that if a prior authorization request is approved for prescription drugs and such prescription drugs have been scheduled, provided, or delivered to the patient consistent with the authorization, the carrier shall not revoke, limit, condition, modify, or restrict that authorization unless (i) there is evidence that the authorization was obtained based on fraud or misrepresentation; (ii) final actions by the U.S. Food and Drug Administration, other regulatory agencies, or the manufacturer remove the drug from the market, limit its use in a manner that affects the authorization, or communicate a patient safety issue that would affect the authorization alone or in combination with other authorizations; (iii) a combination of drugs prescribed would cause a drug interaction; or (iv) a generic or biosimilar is added to the prescription drug formulary. The bill provides that such provisions do not require a carrier to cover any benefit not otherwise covered or cover a prescription drug if the enrollee is no longer covered by a health plan on the date the prescription drug was scheduled, provided, or delivered. This bill is identical to HB 1134.

Health insurance; prior authorization. Requires that any provider contract between a carrier and a participating health care provider contain specific provisions that require that if a prior authorization request is approved and services and supplies have been scheduled, provided, or delivered to the patient consistent with the authorization, the carrier shall not revoke, limit, condition, modify, or restrict that authorization unless (i) there is evidence that the authorization was obtained based on fraud or misrepresentation; (ii) final actions by the U.S. Food and Drug Administration, other regulatory agencies, or the manufacturer remove the drug from the market, limit its use in a manner that affects the authorization, or communicate a patient safety issue that would affect the authorization alone or in combination with other authorizations; (iii) a combination of drugs prescribed would cause a drug interaction; or (iv) a generic or biosimilar is added to the prescription drug formulary. The bill provides that such provisions do not require a carrier to cover any benefit not otherwise covered or cover a prescription drug if the enrollee is no longer covered by a health plan on the date the prescription drug was scheduled, provided, or delivered.

Health insurance; prior authorization. Requiresthat any provider contract between a carrier and a participatinghealth care provider contain specific provisions that prohibit thecarrier from revoking, limiting, conditioning, modifying, or restrictinga prior authorization if such prior authorization request has beenapproved and services, drugs, or supplies have been provided or deliveredto the patient consistent with such prior authorization unless thereis evidence that the request was approved based on fraud or misinformation.The bill also extends from 30 days to 90 days the period of a member'sprescription drug benefit coverage under a new health plan duringwhich a carrier is required to honor a prior authorization by anothercarrier.