Sec. FFF-1. 22 MRSA §2699, sub-§2, ¶B, as enacted by PL 2003, c. 456, §1, is repealed.
Sec. FFF-2. 22 MRSA §2699, sub-§2, ¶E, as enacted by PL 2003, c. 456, §1, is amended to read:
E. With regard to the dispensation of a substitute prescription drug for a prescribed drug to a covered individual the following provisions apply.
(1) The pharmacy benefits manager may substitute a lower-priced generic and therapeutically equivalent drug for a higher-priced prescribed drug.
(2) With regard to substitutions If a pharmacy benefits manager makes a substitution in which the substitute drug costs more than the prescribed drug, the substitution must be made for medical reasons that benefit the covered individual and must benefit the covered entity. If a substitution is being made under this subparagraph, the pharmacy benefits manager shall obtain the approval of the prescribing health professional or that person's authorized representative after disclosing disclose to the covered individual and the covered entity the cost of both drugs and any benefit or payment directly or indirectly accruing to the pharmacy benefits manager as a result of the substitution.
(3) The pharmacy benefits manager shall transfer in full to the covered entity any benefit or payment received in any form by the pharmacy benefits manager either as a result of a prescription drug substitution under subparagraph (1) or (2) or as a result of the pharmacy benefits manager's substituting a lower-priced generic and therapeutically equivalent drug for a higher-priced prescribed drug.
Sec. FFF-3. PL 2003, c. 513, Pt. W, §1 is amended to read:
Sec. W-1. Implementation of incentive payments; rulemaking. Notwithstanding any other provision of law, the Department of Human Services shall adopt routine technical rules to implement incentive payments within existing resources to pharmacies, based on criteria, including, but not limited to, length of time participating in the Maine Rx Plus and drugs for the elderly programs, status as sole community or independent providers and volume of publicly funded beneficiaries. Rules adopted pursuant to this section are routine technical rules as defined in the Maine Revised Statutes, Title 5, chapter 375, subchapter 2-A.
Sec. FFF-4. Subcommittee of MaineCare Advisory Committee to review prior authorization process. The MaineCare Advisory Committee shall establish a standing subcommittee to review the prior authorization process used in MaineCare and the Drugs for the Elderly benefit programs and to make recommendations to the Department of Human Services related to their operation. Membership on the subcommittee consists of members of the MaineCare Advisory Committee, providers and experts in prior authorization from private insurance and private purchasers and any additional experts considered necessary by the committee to achieve the purposes of this section. The subcommittee may not exceed 15 members.
The department shall work with the subcommittee to examine the following issues.
1. Consumer education. The subcommittee shall determine the most effective means of providing educational information to members of MaineCare and Drugs for the Elderly, both electronically and otherwise, related to the prior authorization process, including but not limited to:
A. Provision for accessing drugs requiring prior authorization in an emergency or on a one-time basis before a prior authorization request has been approved;
B. The right to request an administrative hearing when the Department of Human Services fails to act on a request for prior authorization or prior authorization has been denied, including the right to receive benefits pending the hearing under certain circumstances;
C. Procedural requirements of the prior authorization process, including the Department of Human Services' responsibility to process a completed prior authorization request within at least 24 hours;
D. An easily accessible, understandable, complete and up-to-date list of drugs subject to prior authorization together with all information related to preferred drugs, dosage requirements and step therapies; and
E. Refill policies, including early refill policies and any exceptions to those policies.
2. Prior authorization process. The subcommittee shall review the current prior authorization process and make recommendations to the Department of Human Services as to how it can be simplified or improved. In particular, the subcommittee shall review:
A. Verification required of providers in support of their request for prior authorization;
B. The specificity of notices given to providers and members when a prior authorization request has been deferred or denied;
C. Time periods for processing prior authorization requests;
D. The adequacy of the fair hearing process including examining the need for an expedited hearings process to be used in certain circumstances; and
E. The step therapy process, including examining whether exceptions should be made under certain circumstances for frail or other particularly vulnerable members.
3. Quality assurance. The subcommittee shall explore the value of the Department of Human Services' conducting a periodic survey of a representative sample of MaineCare members to examine the experience of members whose request for prior authorization is delayed or denied, including whether or not they experienced adverse health consequences or undesirable side effects or required the use of additional services such as physician, hospital or transportation services as a result of a denial or delay.
4. Drug Utilization Review Committee. The subcommittee shall review any MaineCare Advisory Committee members' concerns about the Drug Utilization Review Committee, including any concerns about the process for public input into the Drug Utilization Review Committee meetings.
5. Rules. The subcommittee shall examine the current practices and policies related to the prior authorization process to determine which, if any, of these the subcommittee would recommend be adopted in the form of rules in accordance with the Maine Revised Statutes, Title 5, chapter 375.
By February 1, 2005, the Department of Human Services shall submit a report to the joint standing committee of the Legislature having jurisdiction over health and human services matters, including the findings and recommendations of the subcommittee and the department's response to each of those recommendations. The joint standing committee may report out legislation to the First Regular Session of the 122nd Legislature related to the use of prior authorization in programs or benefits implemented under the Maine Revised Statutes, Title 22, chapter 101 or 855.
Sec. FFF-5. Appropriations and allocations. The following appropriations and allocations are made.
HUMAN SERVICES, DEPARTMENT OF
Medical Care - Payments to Providers 0147
Initiative: Deappropriates and allocates funds to reflect the distribution of funds to the MaineCare program from Mylan Labs settlement proceeds.
General Fund 2003-04 2004-05
All Other $0 ($124,014)
__________ __________
General Fund Total $0 ($124,014)
Other Special Revenue Funds 2003-04 2004-05
All Other $0 $124,014
__________ __________
Other Special Revenue
Funds Total $0 $124,014
Bureau of Medical Services 0129
Initiative: Appropriates and allocates funds for contractual services related to implementing stricter prior authorization, increased invoicing for rebates and additional pharmacist support.
General Fund 2003-04 2004-05
All Other $0 $250,000
__________ __________
General Fund Total $0 $250,000
Federal Expenditures Fund 2003-04 2004-05
All Other $0 $650,000
__________ __________
Federal Expenditures Fund Total $0 $650,000
Bureau of Medical Services 0129
Initiative: Appropriates and allocates funds for contractual services for increased claims processing support, system changes and drug file management.
General Fund 2003-04 2004-05
All Other $0 $250,000
__________ __________
General Fund Total $0 $250,000
Federal Expenditures Fund 2003-04 2004-05
All Other $0 $650,000
__________ __________
Federal Expenditures Fund Total $0 $650,000
Medical Care - Payments to Providers 0147
Initiative: Deappropriates and deallocates funds in the MaineCare pharmacy initiatives, including review of pharmacy use in certain supervised settings, stricter prior authorization criteria for the preferred drug list and request for federal permission to waive freedom of choice.
General Fund 2003-04 2004-05
All Other $0 ($6,250,000)
__________ __________
General Fund Total $0 ($6,250,000)
Federal Expenditures Fund 2003-04 2004-05
All Other $0 ($11,694,300)
__________ __________
Federal Expenditures Fund Total $0 ($11,694,300)
Medical Care - Payments to Providers 0147
Initiative: Deappropriates and deallocates funds by initiating a voluntary pharmacy mail order program for certain specialty drugs on the direct supply drug list and other MaineCare and low-cost drugs for the elderly prescriptions. The department is not authorized to implement any form of mandatory mail order program for the various drug programs referenced in this section or otherwise administered by the department unless the Legislature subsequently provides that authorization.
General Fund 2003-04 2004-05
All Other $0 ($5,000,000)
__________ __________
General Fund Total $0 ($5,000,000)
Federal Expenditures Fund 2003-04 2004-05
All Other $0 ($9,355,440)
__________ __________
Federal Expenditures Fund Total $0 ($9,355,440)
Medical Care - Payments to Providers 0147
Initiative: Appropriates funds to be distributed to pharmacies as incentive payments to mitigate the impact on community pharmacies of initiating a voluntary pharmacy mail order program.
General Fund 2003-04 2004-05
All Other $0 $1,000,000
__________ __________
General Fund Total $0 $1,000,000
Medical Care - Payments to Providers 0147
Initiative: Deappropriates funds as a result of creating a preferred drug list in the Drugs for the Elderly and Disabled program, taking into account available manufacturers' rebates, efficacy and cost-effectiveness in a manner similar to that used under MaineCare.
General Fund 2003-04 2004-05
All Other $0 ($1,000,000)
__________ __________
General Fund Total $0 ($1,000,000)
HUMAN SERVICES, DEPARTMENT OF
DEPARTMENT TOTALS 2003-04 2004-05
GENERAL FUND $0 ($10,874,014)
FEDERAL EXPENDITURES FUND 0 (19,749,740)
OTHER SPECIAL REVENUE
FUNDS 0 124,014
__________ __________
DEPARTMENT TOTAL -
ALL FUNDS $0 ($30,499,740)
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