Bill Text: MI SB0429 | 2011-2012 | 96th Legislature | Engrossed
Bill Title: Insurance; health; standardized prior authorization form for prescription drugs; require. Amends 1956 PA 218 (MCL 500.100 - 500.8302) by adding sec. 2212c. TIE BAR WITH: SB 0430'11
Spectrum: Moderate Partisan Bill (Republican 8-2)
Status: (Engrossed - Dead) 2012-03-29 - Referred To Committee On Insurance [SB0429 Detail]
Download: Michigan-2011-SB0429-Engrossed.html
SB-0429, As Passed Senate, March 29, 2012
SUBSTITUTE FOR
SENATE BILL NO. 429
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
(MCL 500.100 to 500.8302) by adding section 2212c.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
Sec. 2212c. (1) On or before January 1, 2013, the commissioner
shall develop a standard prior authorization methodology for use by
prescribers to request and receive prior authorization from an
insurer when a policy, certificate, or contract requires prior
authorization for prescription drug benefits. The commissioner
shall include in the standard prior authorization methodology the
ability for the prescriber to designate the prior authorization
request for expedited review. In order to designate a prior
authorization request for expedited review, the prescriber shall
certify that applying the 15-day standard review period may
seriously jeopardize the life or health of the patient or the
patient's ability to regain maximum function.
(2) Within 30 days after the effective date of this section,
the commissioner shall appoint a workgroup, the members of which
shall represent insurers, prescribers, pharmacists, hospitals, and
other stakeholders in the development of a standard prior
authorization methodology. The workgroup shall assist in the
development of the standard prior authorization methodology under
subsection (1).
(3) In developing the standard prior authorization methodology
under subsection (1), the commissioner shall hold 1 or more public
hearings to gather input from interested parties. In developing the
standard prior authorization methodology under subsection (1), the
commissioner and workgroup shall consider all of the following:
(a) Existing and potential technologies that could be used to
transmit a standard prior authorization request.
(b) The national standards pertaining to electronic prior
authorization developed by the national council for prescription
drug programs.
(c) Any prior authorization forms and methodologies used in
pilot programs in this state.
(d) Any prior authorization forms and methodologies developed
by the federal centers for medicare and medicaid services.
(4) Beginning on the effective date of this section, an
insurer may specify in writing the materials and information
necessary to constitute a properly completed standard prior
authorization request when a policy, certificate, or contract
requires prior authorization for prescription drug benefits.
(5) If the commissioner develops a paper form as the standard
prior authorization methodology under subsection (1), the paper
form shall meet all of the following requirements:
(a) Consist of not more than 2 pages. However, an insurer may
request and require additional information beyond the 2-page
limitation of this subdivision, if that information is specified in
writing by the insurer under subsection (4). As used in this
subdivision, "additional information" includes, but is not limited
to, any of the following:
(i) Patient clinical information including, but not limited to,
diagnosis, chart notes, lab information, and genetic tests.
(ii) Information necessary for approval of the prior
authorization request under plan criteria.
(iii) Drug specific information including, but not limited to,
medication history, duration of therapy, and treatment use.
(b) Be electronically available.
(c) Be electronically transmissible, including, but not
limited to, transmission by facsimile or similar device.
(6) Beginning July 1, 2014, if an insurer uses a prior
authorization methodology that utilizes an internet webpage,
internet webpage portal, or similar electronic, internet, and web-
based system, the prior authorization methodology described in
subsection (5) does not apply. Subsections (4), (8), and (9) apply
to a prior authorization methodology that utilizes an internet
webpage, internet webpage portal, or similar electronic, internet,
and web-based system.
(7) Beginning July 1, 2014, except as otherwise provided in
subsection (6), an insurer shall use the standard prior
authorization methodology developed under subsection (1) when a
policy, certificate, or contract requires prior authorization for
prescription drug benefits.
(8) Beginning January 1, 2014, a prior authorization request
that has not been certified for expedited review by the prescriber
is considered to have been granted by the insurer if the insurer
fails to grant the request, deny the request, or require additional
information of the prescriber within 15 days after the date and
time of submission of a standard prior authorization request under
this section. If additional information is requested by an insurer,
a prior authorization request under this subsection is not
considered granted if the prescriber fails to submit the additional
information within 15 days after the date and time of the original
submission of a properly completed standard prior authorization
request under this section. If additional information is requested
by an insurer, a prior authorization request is considered to have
been granted by the insurer if the insurer fails to grant the
request, deny the request, or otherwise respond to the request of
the prescriber within 15 days after the date and time of submission
of the additional information. If additional information is
requested by an insurer, a prior authorization request under this
subsection is considered void if the prescriber fails to submit the
additional information within 21 days after the date and time of
the original submission of a properly completed standard prior
authorization request under this section.
(9) Beginning January 1, 2014, a prior authorization request
that has been certified for expedited review by the prescriber is
considered to have been granted by the insurer if the insurer fails
to grant the request, deny the request, or require additional
information of the prescriber within 72 hours after the date and
time of submission of a standard prior authorization request under
this section. If additional information is requested by an insurer,
a prior authorization request under this subsection is not
considered granted if the prescriber fails to submit the additional
information within 72 hours after the date and time of the original
submission of a properly completed standard prior authorization
request under this section. If additional information is requested
by an insurer, a prior authorization request is considered to have
been granted by the insurer if the insurer fails to grant the
request, deny the request, or otherwise respond to the request of
the prescriber within 72 hours after the date and time of
submission of the additional information. If additional information
is requested by an insurer, a prior authorization request under
this subsection is considered void if the prescriber fails to
submit the additional information within 5 days after the date and
time of the original submission of a properly completed standard
prior authorization request under this section.
(10) As used in this section:
(a) "Insurer" means any of the following:
(i) An insurer issuing an expense-incurred hospital, medical,
or surgical policy or certificate.
(ii) A health maintenance organization.
(iii) A health care corporation operating pursuant to the
nonprofit health care corporation reform act, 1980 PA 350, MCL
550.1101 to 550.1704.
(iv) A third party administrator of prescription drug benefits.
(b) "Prescriber" means that term as defined in section 17708
of the public health code, 1978 PA 368, MCL 333.17708.
(c) "Prescription drug" means that term as defined in section
17708 of the public health code, 1978 PA 368, MCL 333.17708.
(d) "Prescription drug benefit" means the right to have a
payment made by an insurer pursuant to prescription drug coverage
contained within a policy, certificate, or contract delivered,
issued for delivery, or renewed in this state.
Enacting section 1. This amendatory act does not take effect
unless Senate Bill No. 430 of the 96th Legislature is enacted into
law.
