| Summary |
With regard to prior authorization requirements imposed by
carriers, private utilization review organizations (organizations), and
pharmacy benefit managers (PBMs) for certain health-care services and
prescription drug benefits covered under a health benefit plan, the bill
requires carriers, organizations, and PBMs, as applicable, to adopt a
program, in consultation with participating providers, to eliminate or
substantially modify prior authorization requirements in a manner that
removes administrative burdens on qualified providers and their patients
with regard to certain health-care services, prescription drugs, or related
benefits based on specified criteria. Additionally, a carrier or organization
is prohibited from denying a claim for a health-care procedure a provider
provides, in addition or related to an approved surgical procedure, under
specified circumstances or from denying an initially approved surgical
procedure on the basis that the provider provided an additional or a
related health-care procedure.
The bill extends the duration of an approved prior authorization for
a health-care service or prescription drug benefit from 180 days to a
calendar year.
Carriers are required to post, on their public-facing websites,
specified information regarding:
•
The number of prior authorization requests that are
approved, denied, and appealed;
•
The number of prior authorization exemptions or
alternatives to prior authorization requirements provided
pursuant to a program developed and offered by the carrier,
an organization, or a PBM; and
•
The prior authorization requirements as applied to
prescription drug formularies for each health benefit plan
the carrier or PBM offers.
The bill applies to conduct occurring on or after January 1, 2026.
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