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Bureau bill would require coverage of equivalent nonformulary drugs during shortages for serious mental illness
Summary
LD 1,100 would codify a Bureau of Insurance bulletin requiring insurers to cover equivalent nonformulary drugs for treating serious mental illness when a formulary drug is in shortage; insurers asked for language that allows use of formulary alternatives before nonformulary coverage is mandated.
The Bureau of Insurance presented LD 1,100 as a department bill to codify bulletin 478, which directed carriers to treat nonformulary drugs prescribed to assess and treat serious mental illness the same as formulary drugs when a formulary drug is unavailable due to shortage.
Bureau counsel said the bill is intended to preserve patient access to necessary behavioral‑health medications during supply disruptions and to resolve a potential inconsistency between two provisions in the insurance code (the counsel cited the relevant Title 24‑A provisions as presented in testimony). The bureau said carriers should not be forced straight into step‑therapy sequences when the prescribed formulary drug is unavailable; carriers should be able to propose reasonable alternatives first, but the bureau wants to avoid unlimited step therapy that would delay access when shortages make a prescriber’s formulary drug unobtainable.
The Maine Association of Health Plans and Anthem testified that they support preserving patient access but asked the committee to clarify language so that plans could direct patients toward formulary substitutes where clinically appropriate before moving to nonformulary drugs. The bureau said it is willing to work on amendment language to preserve the bureau’s intent while allowing reasonable plan management and clinical substitution.
Ending: Stakeholders agreed to work with the bureau on drafting amendments clarifying the sequence of formulary substitute access and protections for patients when shortages occur.
