Maine § 24-A §4311 Access to prescription drugs

Maine Statutes

§ 24-A §4311 — Access to prescription drugs

Maine·Title 24-A MAINE INSURANCE CODE·Ch. 56-A HEALTH PLAN IMPROVEMENT ACT

1.Formulary. If a health plan provides coverage for prescription drugs but the coverage limits such benefits to drugs included in a formulary, a carrier shall: 1-A. Request for clinically appropriate prescription drugs. For plan years beginning on or after March 19, 2019, a carrier must allow an enrollee, the enrollee's designee or the person who has issued a valid prescription for the enrollee to request a clinically appropriate drug not otherwise covered by the health plan. The carrier's process must comply with section 4304 and with this subsection. If the carrier approves a request under this subsection for a drug not otherwise covered by the health plan, the carrier must treat the drug as an essential health benefit, including counting any cost sharing toward the plan's annual limit

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1.
Formulary.
If a health plan provides coverage for prescription drugs but the coverage limits such benefits to drugs included in a formulary, a carrier shall:
1-A.
Request for clinically appropriate prescription drugs.
For plan years beginning on or after March 19, 2019, a carrier must allow an enrollee, the enrollee's designee or the person who has issued a valid prescription for the enrollee to request a clinically appropriate drug not otherwise covered by the health plan. The carrier's process must comply with section 4304 and with this subsection. If the carrier approves a request under this subsection for a drug not otherwise covered by the health plan, the carrier must treat the drug as an essential health benefit, including counting any cost sharing toward the plan's annual limit on cost sharing and including it when calculating the plan's actuarial value.
2.
Coverage of approved drugs and medical devices.
A carrier that provides coverage for prescription drugs and medical devices may not deny coverage of a prescribed drug or medical device on the basis that the use of the drug or device is investigational if the intended use of the drug or device is included in the labeling authorized by the federal Food and Drug Administration or if the use of the drug or device is recognized in one of the standard reference compendia or in peer-reviewed medical literature.
2-A.
Coverage of prescription during emergency declared by the Governor.
Except as provided in this subsection, a carrier shall provide coverage for the furnishing or dispensing of a prescription drug in accordance with a valid prescription issued by a provider in a quantity sufficient for an extended period of time, not to exceed a 180-day supply, during a statewide state of emergency declared by the Governor in accordance with Title 37‑B, section 742. This subsection does not apply to coverage of prescribed contraceptive supplies furnished and dispensed pursuant to section 2756, 2847‑G or 4247 or coverage of opioids prescribed in accordance with limits set forth in Title 32.
3.
Construction.
This section may not be construed to require a carrier to provide coverage of prescription drugs or medical devices.
4.
Application.
The requirements of this section apply to all individual and group policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.

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Legislative History

PL 1999, c. 742, §19 (NEW). PL 1999, c. 742, §21 (AFF). PL 2003, c. 517, §B32 (AMD). PL 2017, c. 429, Pt. A, §1 (AMD). PL 2017, c. 429, Pt. A, §2 (AFF). PL 2019, c. 5, Pt. A, §21 (AMD). PL 2019, c. 273, §3 (AMD). PL 2021, c. 28, Pt. B, §1 (AMD). RR 2023, c. 2, Pt. A, §38 (COR). PL 2025, c. 473, §2 (AMD).