[{"_1":2,"_100":-5,"_101":-5},"loaderData",{"_3":4,"_26":27},"root",{"_5":6,"_17":10,"_18":19,"_20":21,"_22":10,"_23":-5,"_24":-5,"_25":10},"user",{"_7":8,"_9":10,"_11":10,"_12":-5,"_13":-5,"_14":15,"_16":-5},"roles",[],"isAuthenticated",false,"isPremium","planName","subscriptionStatus","featureFlags",{},"insightsBudget","isDevelopmentHost","userPreferences",{},"recaptchaSiteKey","6LcvOJcUAAAAAHsB-gPGfGktcRlKpH7OTIU_dMTD","isImpersonating","impersonation","affiliateStatus","isFreedomPortal","routes/v2/article/layout",{"_28":29,"_30":31},"notFound",true,"relatedArticles",[32,76,88],{"_33":34,"_35":36,"_37":38,"_39":40,"_41":42,"_43":44,"_45":46,"_47":48,"_49":50,"_51":52,"_53":54,"_55":56,"_57":58,"_59":60,"_61":62,"_63":64,"_65":66,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},"mediaId",6317114,"mediaKeyId","2375018-c64f2989dfd5a60527e0d54e0b30bd60","parentId",2375018,"title","Montana bill would bar retroactive denials, set standards for off‑label biologic use in minors","audioSeconds",2689,"startMs",247000,"endMs",2936000,"viewUrl","/Search/View?dp=1&key=2375018-c64f2989dfd5a60527e0d54e0b30bd60&start=247&end=2936","thumbnailUrl","https://assets.pipeline.soar.com/2375018-c64f2989dfd5a60527e0d54e0b30bd60/thumbnail_247000.jpg","articleUrl","/articles/6317114/Montana/Montana-bill-would-bar-retroactive-denials-set-standards-for-offlabel-biologic-use-in-minors","mediaUrl","https://secure.pipeline.soar.com/6317114-6a046cb3cbf721e073914cfb5cdc94ab/orig.mp4?Expires=1771191786&Signature=f5y2BjhIqnYVLy9HLWNLEwny8fsY-m5ae1mQTQSABsHW22mrTMUit2bz6voxctlktJztD-a0Mr7TeAuPErvSmu9pFVDP3qNoqoXSG97q5WwExBxEKvh3n6UrQzvHRQ4qou7fh5xshig0OwrczIoSMGBXIsUgRJOBXM1~Q80n10LVdtNTKgTuzpMqed-3qZLWXnjHpMFWBD-ME5W9DHWUKo34yrfm1TaMIpUV4KJ6HlZX6~PBpmI01qaOdwZ5vIrid09JTXOK2NBExUXifgx7E1kAsmpBqEpyRack2WDe8qnFrQYv6wlApWSKK95YpxC1JOxkxZgXcVCWRXTkkI3WsA__&Key-Pair-Id=KUT5TJCACFTXG","author","Montana Legislature","date","2025-02-21T00:00:00Z","article","Representative Ed Buttrell introduced House Bill 544 in the House Business and Labor Committee, saying the bill would stop most retroactive denials by insurers and set standards for when insurers may require prior authorization for biologic therapies used in minors.

The bill disallows retroactive denials except in the case of fraud, misrepresentation, nonpayment of premium or exhaustion of benefits. It also requires that off‑label use of biologic therapies for minors be supported by medical literature in at least two peer‑reviewed journals and that insurers respond to properly documented prior‑authorization requests within the timelines already established in Title 33, chapter 32 of Montana law. Section 3 would extend similar requirements to the State Employees’ Group Benefits Plan and the Montana University System group benefits plan.

Why it matters: Doctors and family members said the current prior‑authorization and retroactive‑denial practices can delay life‑saving treatments and impose large, unanticipated costs on families. Several speakers said the most urgent cases involve children with very early onset inflammatory and autoimmune conditions for whom biologics—often not labeled by the Food and Drug Administration (FDA) for young patients—can be the difference between outpatient treatment and repeated hospitalizations.

Clinicians, parents and advocates described lengthy appeals and delayed approvals. ‘‘There is a rigorous process to go through to get FDA approval,’’ said Kim Longcake, an advanced nurse practitioner who specializes in pediatric gastroenterology, and added that manufacturers often do not seek pediatric labeling because of small patient numbers. She told the committee she has ‘‘horror stories for days’’ about patients who waited months for approvals and were repeatedly hospitalized in the interim.

Parents described the financial and emotional stakes. Rachel Markovich, who testified as a mother and founder of the nonprofit VEO Guardians, said her son was prescribed a biologic in 2022 and the family faced months of denials and delays while his condition worsened; she said the medication cost roughly $5,000 per dose and charity is not a sustainable substitute for insurance coverage.

Medical groups including the Montana Medical Association, the Montana Hospital Association and the Montana chapter of the American Academy of Pediatrics testified in support. Attorneys and drafters who assisted the bill told the committee they negotiated the language with payers and other stakeholders to narrow the exceptions and address payer concerns.

No committee vote or formal action was recorded in the transcript excerpt.

The hearing record: proponents urged passage and told personal stories about delays and retroactive denials; there were no opponents or informational witnesses listed in the hearing record provided. Representative Buttrell closed by asking the committee to advance the bill; the hearing ended with the chair closing the record on House Bill 544.","mediaType","Video","parentTitle","House Business and Labor Feb 21, 2025","oneSentenceSummary","Representative Ed Buttrell introduced House Bill 544 to bar most retroactive insurer denials and to set standards for prior authorization of off‑label biologic therapies for minors.","taxTitle","2025 Legislature MT, Montana","taxId",77694,"location","Montana","headline","","shortSummary",{"_33":77,"_35":36,"_37":38,"_39":78,"_41":79,"_43":80,"_45":81,"_47":82,"_49":83,"_51":84,"_53":85,"_55":56,"_57":58,"_59":86,"_61":62,"_63":64,"_65":87,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},6317104,"Bill to remove prior authorization for many generics and time‑sensitive drugs draws broad clinical support, insurer objections",2570,9783000,12353000,"/Search/View?dp=1&key=2375018-c64f2989dfd5a60527e0d54e0b30bd60&start=9783&end=12353","https://assets.pipeline.soar.com/2375018-c64f2989dfd5a60527e0d54e0b30bd60/thumbnail_9783000.jpg","/articles/6317104/Montana/Bill-to-remove-prior-authorization-for-many-generics-and-timesensitive-drugs-draws-broad-clinical-support-insurer-objections","https://secure.pipeline.soar.com/6317104-7f347b51ae4d084e4641759917a784d5/orig.mp4?Expires=1771191786&Signature=VtzB68sYstw-UYHnFySZH43v686TC7QQaVJAMcy59mW9ZbfREz4aob8Wr-i~XnPY69zwRPlIW6KwVeE1pZpewjzbhGdWxUTesX~B6KpFlWXvswZh~VnQtInvapE9ksDq-0QzcVCB8WrzgNQDeX8qDVTFXv5C0ukM2JY9w8Uk3EZvnMRyO2-EITpWxysi0n3v-Xq0kscONS0lcMkJCJjLMG7eb5N2YudmdYYGF~JOcBoF5SM0gdvTGxtXBrPuCHDl29BA3-tI23j5h9-xG~tHM2duyi2RXoRHRNXqd8NGUnwRbnF7v-m5Aos~ghbRi06iVe1v84Vx6kHKXnS9EM-VEQ__&Key-Pair-Id=KUT5TJCACFTXG","Representative Jonathan Karlen opened the hearing on House Bill 399, which would prohibit prior authorization for oral or inhaled non‑biologic generic prescription drugs and for certain time‑sensitive medications identified in the bill (for example, inhalers and insulin). The sponsor said he and negotiators accepted an amendment requested by payers excluding biologic and specialty medications (those defined using Medicare Part D and higher‑cost specialty definitions) to the carve‑out.

Why it matters: Supporters said prior authorization on inexpensive generics and essential, time‑sensitive drugs produces unnecessary delays that can result in emergency room visits, hospitalizations, or interruptions in chronic disease management. They urged the committee to remove what they described as red tape that produces downstream costs and harms.

Clinical testimony and examples: Clinicians from primary care, pediatrics, allergy and immunology, endocrinology, and community health centers described repeated examples of patients harmed or put at greater risk by delays. Dr. Saul Rivard said he spent more than an hour of clinic time on one generic prior authorization for tamsulosin, a low‑cost drug. Pediatric and allergy specialists recounted asthma patients who could not obtain the inhaler prescribed and later presented to emergency care. Dr. Sommer Monforte, an allergist, testified that some insurers require that children try multiple preferred formulary inhalers—even if they are clinically similar—before approving the prescribed medication; she said one patient required intensive‑care treatment after such delays.

Tribal health and rural providers: Alissa Snow, testifying for several tribal communities, described frequent disruptions in consistent coverage for people who change jobs or move; she said those gaps often require re‑authorizations and can undermine chronic disease control, particularly for diabetes where insulin continuity is essential.

Supporters included the Montana Academy of PAs, Montana Academy of Family Physicians, Montana Medical Association, Montana Hospital Association, Montana Pharmacy Association, tribal health representatives and community health centers. Pharmacists and clinic staff detailed the time required to manage prior authorizations and how delays force extra trips to pharmacies.

Opponents: Insurers, PBMs and industry groups opposed broad removal of prior authorization on generics. They argued that formularies and prior‑authorization rules help ensure clinical safety, avoid duplicative care and manage drug costs for the insurer’s risk pool. Cigna, Blue Cross Blue Shield of Montana, PacificSource, AHIP and PBM trade groups said some generics can vary substantially in price by formulation and that allowing insurers to manage formularies and require prior authorization for non‑formulary options preserves the ability to steer patients toward lower‑cost appropriate options. PBMs and insurers proposed maintaining prior authorization for non‑formulary drugs and for specialty items excluded by the sponsor’s accepted amendment.

Technical and administrative issues: Several opponent witnesses emphasized the role of pharmacy benefit managers and P&T (pharmacy and therapeutics) committees in evaluating drug efficacy and safety, and cautioned that removing prior authorization for a broad category could shift costs to premiums or limit insurers’ ability to negotiate prices.

The committee heard many proponents’ personal stories and clinicians’ examples of harms from prior authorization delays; insurers asked for narrow carve‑outs and technical amendments to preserve safety and plan solvency. No formal vote was recorded in the transcript excerpt.","House Bill 399 would bar prior authorization for many low‑cost generic oral and inhaled drugs and for certain urgent medications, with proponents saying the change would reduce dangerous delays and administrative burdens.",{"_33":89,"_35":36,"_37":38,"_39":90,"_41":91,"_43":92,"_45":93,"_47":94,"_49":95,"_51":96,"_53":97,"_55":56,"_57":58,"_59":98,"_61":62,"_63":64,"_65":99,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},6317108,"Committee hears wide support and insurer concerns for prior‑authorization reform bill",6801,2979000,9780000,"/Search/View?dp=1&key=2375018-c64f2989dfd5a60527e0d54e0b30bd60&start=2979&end=9780","https://assets.pipeline.soar.com/2375018-c64f2989dfd5a60527e0d54e0b30bd60/thumbnail_2979000.jpg","/articles/6317108/Montana/Committee-hears-wide-support-and-insurer-concerns-for-priorauthorization-reform-bill","https://secure.pipeline.soar.com/6317108-f2466a4947ebdece5c4038c79efaeb84/orig.mp4?Expires=1771191787&Signature=Gy6-bJd75oiBzDrWugvhRAoy2HGNg~IMRLHrc2RiTp8jz5P15yYCxUoggaEi02ZrxwrteDu~ZFq3jOroN4gnzHiihsaZPcacCZ6tHzNeQ8VWUEMvR31AjpGmMCF7bZGol~7lzNKYPVZLzH3q95ADGOjrHYIbxJ4at25gSrmNkDVggr5Qs-Qse6ElLAw2Q-lhzRP7b6QldlqHAdfA~q7~CYR1jadn-C1HJB-lW2Pvy3i8LLNhfZp4rVRiPvc5IbRP8teO5k458HUVlRU0dcCEWVqiQ-Gy8458BcqP0ZuBB4EozD-GXrxxaR6Dfc3DwRD4lNhJtGAhZLaZVh~PbQ7XUA__&Key-Pair-Id=KUT5TJCACFTXG","Representative Jonathan Karlen opened the committee hearing on House Bill 398, which he described as a negotiated effort to reduce delays and administrative burdens associated with prior authorization while preserving patient safety.

Major provisions in the bill and sponsor amendment include: honoring existing prior authorizations for at least three months when a patient changes insurance plans; requiring that adverse (denial) determinations be made by a reviewer with clinical expertise focused on the diagnosis and treatment at issue; extending standard prior‑authorization approvals from three to six months and, for defined chronic conditions, to 12 months; and defining ‘‘chronic condition’’ by reference to the Centers for Disease Control and Prevention (CDC) definition.

Why it matters: Physicians and hospital advocates told the committee the current prior‑authorization regime creates time‑consuming administrative work and can harm patients through delays. Dr. Saul Rivard, president of the Montana Academy of Family Physicians, said prior authorization is “among the heaviest administrative burdens” and can contribute to physician burnout. Pharmacy and hospital advocates said staff spend sizeable portions of their work hours handling authorizations.

Supporters: A broad coalition of clinicians and health organizations testified in favor, including the Montana Academy of Family Physicians, Montana Medical Association, Montana Hospital Association, Montana Pharmacy Association, the Montana chapter of the American Academy of Pediatrics, the Montana Primary Care Association and the Montana Nurses Association. Several clinicians gave examples of patients whose treatment was delayed: one pediatric patient waited months for a biologic that restored vision for some but not all patients after long delays, a family described repeated hospitalizations during authorization waits, and clinic staff reported spending up to 40% of work time on authorizations in some specialty settings.

Opponents and concerns: Insurers and pharmacy benefit managers (PBMs) opposed parts of the bill or sought amendments. Blue Cross Blue Shield of Montana, Cigna, AHIP, the Mountain Health Co‑op and national PBM trade groups asked for narrower language on who must make adverse determinations, saying routine or clerical denials do not require specialty‑matched reviewers and that forcing specialty matching for every denial would slow turnaround and raise administrative costs. Blue Cross cited average pre‑service decision times of about 2.5 days and warned that requiring external specialty reviewers for many determinations could lengthen decision times and raise plan costs. Several insurer witnesses proposed amendments that would preserve specialty matching for appeals and complex clinical peer‑to‑peer reviews while allowing faster administrative determinations for routine cases.

Clarifications and limits: Sponsors and proponents said the bill was negotiated with payers and represents compromise language; insurers said a remaining sticking point focused on section 2 (specialty matching for adverse determinations) and proposed an amendment to narrow its scope. Several witnesses suggested a January 1, 2026 effective date to match plan years and implementation schedules.

No formal committee votes were recorded in the provided transcript excerpt. The hearing record includes extended testimony from both provider and payer interests; committee members asked about timelines, patient safety exceptions and administrative impacts.","Rep. Jonathan Karlen told the House Business and Labor Committee that House Bill 398 would require continuity of prior‑authorization decisions when patients switch plans, specialty‑matched reviewers for clinical denials, and longer authorization periods for chronic care.","actionData","errors"]

Article not found

Montana bill would bar retroactive denials, set standards for off‑label biologic use in minors

Bill to remove prior authorization for many generics and time‑sensitive drugs draws broad clinical support, insurer objections

Committee hears wide support and insurer concerns for prior‑authorization reform bill