FIFTY-FOURTH LEGISLATURE

FIRST SESSION, 2019

March 8, 2019

Mr. Speaker:

    Your HEALTH & HUMAN SERVICES COMMITTEE, to whom has been referred

SENATE JUDICIARY COMMITTEE SUBSTITUTE FOR SENATE PUBLIC AFFAIRS COMMITTEE SUBSTITUTE FOR

 SENATE BILL 188

has had it under consideration and reports same with recommendation that it DO PASS, amended as follows:

1. On page 7, line 21, after "requests", insert "to approve or pend a request for benefits".

     2. On page 9, between lines 1 and 2, insert the following new subsections:

          "D. Upon denial of a covered person's prior authorization request based on a finding that a prescription drug is not on the covered person's health benefits plan formulary, a health insurer shall notify the person of the denial and include in a conspicuous manner information regarding the person's right to initiate a drug formulary exception request and the process to file a request for an exception to the denial.

          E. An auto-adjudicated prior authorization request based on medical necessity that is pended or denied shall be reviewed by a health care professional from the same or similar practice specialty as that which forms the basis for the medical necessity. The health care professional shall make a final determination of the request. If the request is denied after review by a health care professional, notice of the denial shall be provided to the covered person and covered person's provider with the grounds for the denial and a notice of the right to appeal and describing the process to file an appeal.

          F. A health insurer shall establish a process by which a health care provider or covered person may initiate an electronic appeal of a denial of a prior authorization request."

     3. Reletter the succeeding subsections accordingly.

     4. On page 9, line 8, after "a", insert "covered person or a".

     5. On page 9, line 10, after "review", insert "of an expedited prior authorization request made pursuant to Subsection B of this section".