Senate Study Bill 1164 - Introduced SENATE FILE _____ BY (PROPOSED COMMITTEE ON HUMAN RESOURCES BILL BY CHAIRPERSON RAGAN) A BILL FOR An Act requiring the development and use of a standard form for 1 prior authorization of prescription drug benefits. 2 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 3 TLSB 2161SC (2) 85 av/nh

S.F. _____ Section 1. NEW SECTION . 505.26 Prior authorization for 1 prescription drug benefits —— standard form. 2 1. The commissioner shall develop, by rule, a standard prior 3 authorization form for use by health carriers that require 4 prior authorization for prescription drug benefits pursuant to 5 a health benefit plan, by January 1, 2014. 6 2. Prior to development of the standard prior authorization 7 form, the commissioner shall hold at least one public hearing 8 to gather input in developing the standard form from interested 9 parties. 10 3. The standard prior authorization form shall meet all of 11 the following requirements: 12 a. Not exceed two pages in length. 13 b. Be available in an electronic format. 14 c. Be transmissible in an electronic format. 15 4. Health carriers shall use and accept the standard prior 16 authorization form beginning on July 1, 2014. Health care 17 providers shall use and submit the standard prior authorization 18 form, when prior authorization is required by a health benefit 19 plan, beginning on July 1, 2014. 20 5. If a health carrier fails to use or accept the standard 21 prior authorization form or to respond to a health care 22 provider request for prior authorization of prescription drug 23 benefits within forty-eight hours of the health care provider’s 24 submission of the form, the request for prior authorization 25 shall be considered to be approved. 26 6. As used in this section: 27 a. “Facility” means an institution providing health care 28 services or a health care setting, including but not limited 29 to hospitals and other licensed inpatient centers, ambulatory 30 surgical or treatment centers, skilled nursing centers, 31 residential treatment centers, diagnostic, laboratory, and 32 imaging centers, and rehabilitation and other therapeutic 33 health settings. 34 b. “Health benefit plan” means a policy, contract, 35 -1- LSB 2161SC (2) 85 av/nh 1/ 3

S.F. _____ certificate, or agreement offered or issued by a health carrier 1 to provide, deliver, arrange for, pay for, or reimburse any of 2 the costs of health care services. 3 c. “Health care professional” means a physician or other 4 health care practitioner licensed, accredited, registered, or 5 certified to perform specified health care services consistent 6 with state law. 7 d. “Health care provider” or “provider” means a health care 8 professional or a facility. 9 e. “Health care services” means services for the diagnosis, 10 prevention, treatment, cure, or relief of a health condition, 11 illness, injury, or disease. 12 f. “Health carrier” means an entity subject to the 13 insurance laws and regulations of this state, or subject 14 to the jurisdiction of the commissioner, including an 15 insurance company offering sickness and accident plans, a 16 health maintenance organization, a nonprofit health service 17 corporation, a plan established pursuant to chapter 509A 18 for public employees, or any other entity providing a plan 19 of health insurance, health care benefits, or health care 20 services. “Health carrier” includes, for purposes of this 21 section, an organized delivery system. 22 EXPLANATION 23 This bill requires the development and use of a standard form 24 to obtain prior authorization for prescription drug benefits 25 under a health benefit plan. 26 The bill requires the commissioner of insurance to develop, 27 by rule, a standard form by January 1, 2014. Before developing 28 the form, the commissioner is required to hold at least one 29 public hearing to obtain input from interested parties on the 30 form. The form must not exceed two pages in length and must be 31 available and transmissible in an electronic format. 32 Health carriers are required to use and accept the standard 33 prior authorization form, and health care providers are 34 required to use and submit the form, beginning on July 1, 2014. 35 -2- LSB 2161SC (2) 85 av/nh 2/ 3

S.F. _____ If a health carrier fails to use or accept the standard form 1 or to respond to a health care provider’s request for prior 2 authorization of prescription drug benefits within 48 hours of 3 the provider’s submission of the form, the request shall be 4 considered to be granted. 5 -3- LSB 2161SC (2) 85 av/nh 3/ 3