A 2012 Maryland law requires payors and pharmacy benefit managers to offer electronic preauthorization, including:
1) online access to a list of all medical services and pharmaceuticals that require preauthorization and the criteria for making a preauthorization determination;
2) online system to receive preauthorization requests electronically and assign a unique ID to each request; and
3) approval for all electronic preauthorization requests for pharmaceuticals in real-time or within one business day of receiving all pertinent information and two business days for non-urgent medical services.
Click here for payor links to online lists of services/medications and electronic preauthorizations.
In 2014, the law was amended to require payors to establish an electronic process that allows providers to override a step therapy or fail-first protocol when submitting pharmaceutical preauthorization requests. Members should be aware that they can override under the following circumstances (see section 10.25.17.03(D)):
- The step therapy drug has not been approved by the FDA for the medical condition being treated; or
- A prescriber provides supporting medical information to the payor that a prescription drug covered by the payor:
- Was ordered by the prescriber for the insured or enrollee within the past 180 days; and
- Based on the professional judgment of the prescriber, was effective in treating the insured’s or enrollee’s disease or medical condition;
Payors must also notify their insureds about the step therapy override. The regulations, 10.25.17 Benchmarks for Preauthorization of Health Care Services, became effective on October 12, 2015.
Although current law states that physicians must use these systems beginning July 1, the Maryland Health Care Commission (MHCC) has not developed regulations for enforcing this requirement, effectively making it optional. The MHCC has posted related information on its website, including online portals for each of the carriers/PBMs. Following are additional links for related information:
- Electronic preauthorization Flyer
- Electronic Preauthorization Overview
- 2014 Report on State Regulated Payor & Pharmacy Benefit Manager: Preauthorization Benchmark Attainment
- 2013 Report on State Regulated Payor & Pharmacy Benefit Manager: Preauthorization Benchmark Attainment
Dr. Steve Daviss requests that MPS members try using the electronic prior authorization services, whether in- or out-of-network. Please let the MPS know how they are working so we can troubleshoot any problems. He plans to send a link to a form that will collect feedback.
For further questions, please contact Mr. David Sharp at the MHCC: firstname.lastname@example.org or use the general phone number, 410-764-3460.