§ 31–3875.02. Prior authorization requirements and restrictions.

(a)(1) A utilization review entity may only require prior authorization for a covered health care service based on a determination of medical necessity for different care or that the proposed care is experimental or investigational in nature.

(2) A utilization review entity may not require prior authorization:

(A) Based solely on the cost of a covered health care service; provided, that:

(i) Not Funded.

(ii) Not Funded.

(B) For the provision of medication assisted treatment; or

(C) For pre-hospital transportation or for the provision of emergency health care services, including emergency health care services to screen and stabilize an enrollee.

(b) A utilization review entity shall:

(1) Post its current prior authorization requirements and restrictions, including formulary ("prior authorization requirements"), on its website, in a manner accessible to the general public without the need to create an account;

(2) Email or provide a hard copy of the prior authorization requirements to an enrollee, representative, or health care provider upon request by telephone or in writing; and

(3) Provide information on its prior authorization requirements, upon request, to an enrollee, representative, or health care provider over the telephone.

(1) Be described in detail and easily understandable language;

(2) Include any written clinical criteria;

(3) Include a comprehensive listing of all drugs that require prior authorization; and

(4) Include the process for submitting, and standards for considering, including evidence-based guidelines, where possible, requests for:

(A) Prior authorization approval;

(B) Reauthorization of a prior grant of approval; and

(d) If a utilization review entity intends to amend or replace its prior authorization requirements, any changes to the requirements shall not be effective until the utilization review entity's website has been updated to reflect the new requirements.