— response requirements.
1.As used in this section:
a.“Facility”, “health benefit plan”, “health care professional”, “health care provider”,
“health care services”, and “health carrier” mean the same as defined in section 514J.102.
b.“Pharmacy benefits manager” means the same as defined in section 510B.1.
2.The commissioner shall develop, by rule, a process for use by each health carrier and
pharmacy benefits manager that requires prior authorization for prescription drug benefits
pursuant to a health benefit plan, to submit, on or before January 1, 2015, a single prior
authorization form for approval by the commissioner, that each health carrier or pharmacy
benefits manager shall be required to use beginning on July 1, 2015. The process shall
provide that if a prior authorization for
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— response requirements.
1. As used in this section:
a. “Facility”, “health benefit plan”, “health care professional”, “health care provider”,
“health care services”, and “health carrier” mean the same as defined in section 514J.102.
b. “Pharmacy benefits manager” means the same as defined in section 510B.1.
2. The commissioner shall develop, by rule, a process for use by each health carrier and
pharmacy benefits manager that requires prior authorization for prescription drug benefits
pursuant to a health benefit plan, to submit, on or before January 1, 2015, a single prior
authorization form for approval by the commissioner, that each health carrier or pharmacy
benefits manager shall be required to use beginning on July 1, 2015. The process shall
provide that if a prior authorization form submitted to the commissioner by a health carrier
or pharmacy benefits manager is not approved or disapproved within thirty days after its
receipt by the commissioner, the form shall be deemed approved.
3. The commissioner shall develop, by rule, a standard prior authorization process which
meets all of the following requirements:
a. Health carriers and pharmacy benefits managers shall allow health care providers to
submit a prior authorization request electronically.
b. Health carriers and pharmacy benefits managers shall provide that approval of a prior
authorization request shall be valid for a minimum length of time in accordance with the
rules adopted under this section. In adopting the rules, the commissioner may consult with
health care professionals who seek prior authorization for particular types of drugs, and as
the commissioner determines to be appropriate, negotiate standards for such minimum time
periods with individual health carriers and pharmacy benefits managers.
c. Healthcarriersandpharmacybenefitsmanagersshallmakethefollowingavailableand
accessible on their internet sites:
(1) Priorauthorizationrequirementsandrestrictions, includingalistofdrugsthatrequire
prior authorization.
(2) Clinical criteria that are easily understandable to health care providers, including
clinicalcriteriaforreauthorizationofapreviouslyapproveddrugafterthepriorauthorization
period has expired.
(3) Standards for submitting and considering requests, including evidence-based
guidelines, when possible, for making prior authorization determinations.
d. Health carriers shall provide a process for health care providers to appeal a prior
authorization determination as provided in chapter 514J. Pharmacy benefits managers shall
provide a process for health care providers to appeal a prior authorization determination
that is consistent with the process provided in chapter 514J.
4. In adopting a standard prior authorization process, the commissioner shall consider
national standards pertaining to electronic prior authorization, such as those developed by
the national council for prescription drug programs.
5. Apriorauthorizationformapprovedbythecommissionershallmeetallofthefollowing
requirements:
a. Not exceed two pages in length, except that a prior authorization form may exceed that
length as determined to be appropriate by the commissioner.
b. Be available in electronic format.
c. Be transmissible in an electronic format or a fax transmission.
6. Beginning on July 1, 2015, each health carrier and pharmacy benefits manager shall
use and accept the prior authorization form that was submitted by that health carrier or
pharmacy benefits manager and approved for the use of that health carrier or pharmacy
benefits manager by the commissioner pursuant to this section. Beginning on July 1,
2015, health care providers shall use and submit the prior authorization form that has
been approved for the use of a health carrier or pharmacy benefits manager, when prior
authorization is required by a health benefit plan.
7. Thecommissionershalladoptrulespursuanttochapter17Athatproviderequirements,
not to exceed seventy-two hours for urgent claims and five calendar days for nonurgent
claims, for a health carrier or pharmacy benefits manager to respond to a health care
provider’s request for prior authorization of prescription drug benefits or to request
additional information from a health care provider concerning such a request.