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.
(Note: This summary applies to this bill as introduced.)