§ 20-3405 — Prior authorization of prescription drugs for chronic pain conditions

A. For a prior authorization request related to a chronic pain condition, the health care services plan or its utilization review agent shall honor a prior authorization that is granted for an approved prescription drug for the earliest of the following:

1. Six months after the date of the prior authorization approval.

2. The last day of the enrollee's coverage under the plan.

B. In relation to a prior authorization described in subsection A of this section, the health care services plan or its utilization review agent may request that the provider submit information to the health care services plan or its utilization review agent indicating that the enrollee's chronic pain condition has not changed and that the continuation of the treatment is not negatively impacting the enrollee's health. If the provider does not respond within five business days after the date on which the request was received, the health care services plan or its utilization review agent may terminate the prior authorization.

C. This section does not apply to:

1. Prescription medications if the United States food and drug administration recommends that the drug be used only for periods of less than six months.

2. Any opioid or benzodiazepine or other schedule I or II controlled substance.

D. This section does not prohibit the substitution of any drug that has received a six-month prior authorization under subsection A of this section when there is a release of a United States food and drug administration-approved comparable brand product or a generic counterpart of a brand product that is listed as therapeutically equivalent in the United States food and drug administration's publication titled approved drug products with therapeutic equivalence evaluations.

E. This section does not prohibit a health care services plan from granting a prior authorization for a duration longer than six months.