SENATE BILL 117

50th legislature - STATE OF NEW MEXICO - first session, 2011

INTRODUCED BY

John M. Sapien

AN ACT

RELATING TO DRUGS; PROVIDING FOR THE STANDARDIZATION OF ELECTRONIC PRIOR AUTHORIZATION OF PRESCRIPTIONS.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

     SECTION 1. SHORT TITLE.--This act may be cited as the "Electronic Prior Authorization of Prescriptions Act".

     SECTION 2. DEFINITION OF E-PRIOR AUTHORIZATION.--As used in the Electronic Prior Authorization of Prescriptions Act, "e-prior authorization" means a requirement that a prescriber obtain approval via electronic media from a health plan to prescribe a specific medication prior to dispensing.

     SECTION 3. E-PRIOR AUTHORIZATION REQUEST TRANSACTION STANDARDIZATION.--On or before June 30, 2012, the board of pharmacy, in consultation with the insurance division of the public regulation commission, shall identify an outline on how best to standardize e-prior authorization request transactions between health care providers and group purchasers with the goal of maximizing administrative simplification and efficiency in preparation for electronic transmission. The provisions of such e-prior authorization request transactions standards shall, at a minimum, include:

          A. health plans allowing for an e-prior authorization approval within forty-eight hours of a request;

          B. allowing for dispensing a seventy-two-hour supply in an emergency;

          C. prior authorization denials resulting in an explanation of benefit for patients similar to any other coverage denial, including communication of appeals rights at the time of denial;

          D. coverage for prescription medications in all therapeutic classes and classes without e-prior authorization restrictions;

          E. access without e-prior authorization provided to more than one drug or device per therapeutic class where more than one drug or device is available;

          F. comprehensive review of all e-prior authorization access restrictions to be conducted at least annually;

          G. coverage of new medications not included in the e-prior authorization restriction list until a determination is made as to whether the new medication shall be included in the e-prior authorization restriction list;

          H. notification to each health care provider and pharmacy of any new e-prior authorization restrictions at least sixty days prior to the effective date of the restriction;

          I. providing the e-prior authorization restriction list to any health care provider or a member of the public upon request; and

          J. establishing a process to review grievances of health care providers and other interested parties concerning denial of e-prior authorization requests.

     SECTION 4. ELECTRONIC DATA INTERCHANGE STANDARDS.--On or before January 1, 2015, the board of pharmacy, in consultation with the insurance division of the public regulation commission, shall develop standards by which health care providers and group purchasers will exchange standard e-prior authorization requests for drugs and devices using electronic data interchange standards, if available, with the goal of alignment with standards that are or will potentially be used nationally.

     SECTION 5. ELECTRONIC PRIOR AUTHORIZATION REQUEST ACCESSIBILITY.--On or before January 1, 2016, e-prior authorization requests shall be accessible and submitted by providers, and accepted by group purchasers, through secure electronic transmissions. Facsimiles shall not be considered electronic submissions. Nothing in the Electronic Prior Authorization of Prescriptions Act shall preclude the option for paper e-prior authorization forms.

     SECTION 6. EFFECTIVE DATE.--The effective date of the provisions of this act is July 1, 2011.

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