For purposes of this subchapter:

(1) “Chronic or long-term condition” means any of the following:

a. A “complex or chronic medical condition” as defined in § 3364(a) of this title.

b. A “rare medical condition” as defined in § 3364(a) of this title.

(2) “Emergency medical condition” means as defined in § 3349(e) of this title.

(3) “Pharmacy benefits manager” means as defined in § 3302A of this title.

(4) “Prior authorization” means a requirement by a carrier or health-insurance plan that providers submit a request or other prior notification to the carrier for evaluation of appropriateness of the request or if the prescription is medically necessary before treatment is rendered. Prior authorization lets the insured and provider know in advance which pharmaceuticals are considered by the insurer to be medically necessary.

A pharmacy benefits manager may not require prior authorization for coverage of a 72-hour supply of medication that is for a noncontrolled substance prescribed for an emergency medical condition.

(a) A prior authorization form for a prescription medication must include a question regarding whether the prescription medication is for a chronic or long-term condition for which the prescription medication may be necessary for the life of the patient.

(b) If a prescriber indicates on a prior authorization form that the prescription medication is for a chronic or long-term condition for which the prescription medication may be necessary for the life of the patient, the pharmacy benefits manager may not request a reauthorization for the same prescription medication more frequently than every 12 months.

(c) In the same communication in which a pharmacy benefits manager or the pharmacy benefits manager’s agent requests a prior authorization for a prescription medication that has therapeutically equivalent medications that do not require a prior authorization from a prescriber, the pharmacy benefits manager or the pharmacy benefits manager’s agent shall provide the prescriber with a list of alternative prescription medications of the same class and family as the requested medication.

(d) Prescribers that utilize e-prescribing shall receive alternate medications from the pharmacy benefits manager for prescription medications that do not require a prior authorization before the completion of the e-prescribing transaction.

(e) A pharmacy benefits manager or the pharmacy benefit manager’s agent shall provide alternative medications for therapeutically equivalent medications to the pharmacy that require prior authorization on the National Council for Prescription Drug Programs response transaction to a denied claim for prior authorization.