Bill > LD1100

This bill clarifies requirements for health insurance carriers regarding access to prescription drugs, particularly for individuals with serious mental illness. Specifically, the bill requires carriers to approve a nonformulary drug if a formulary drug prescribed to assess or treat serious mental illness is unavailable due to a drug shortage and no equivalent formulary drug exists. The bill also modifies language around the process for requesting clinically appropriate drugs not otherwise covered by a health plan, changing the terminology from "access to" to "request for" such drugs. Under the new provisions, carriers must determine and notify the enrollee, their designee, or prescribing healthcare provider about coverage for a requested drug within 72 hours or 2 business days. For urgent situations (called "exigent circumstances"), such as when a patient's health could be seriously jeopardized, carriers must make a coverage decision within 24 hours. If a drug is approved, the carrier must cover it for the duration of the prescription, including refills, and treat it as an essential health benefit. The bill maintains the definition of "serious mental illness" as a mental disorder resulting in serious functional impairment, as defined in the Diagnostic and Statistical Manual of Mental Disorders.

Health and Social Services

https://legislature.maine.gov/legis/bills/display_ps.asp?LD=1100&snum=132