An Act To Clarify The Requirements For Accessing Nonformulary Drugs And Drugs Used To Treat Serious Mental Illness

132nd Legislature (2025-2026) Introduced by Donna Bailey

LD 1100 ends the blanket obligation to cover nonformulary drugs; carriers only approve equivalent nonformulary drugs via PA when a formulary drug is in shortage with no substitute.

Signed by Governor

#formularies #non-formularydrugs #prescriptiondrugs

Purpose

LD 1100 clarifies how health carriers must handle access to nonformulary drugs in two contexts: (1) drugs used to treat serious mental illness and (2) situations in which a formulary drug is subject to a shortage and no formulary equivalent exists. The bill removes a prior statutory requirement that a health plan enrollee be granted access to a clinically appropriate drug that is not otherwise covered by the plan.

The bill was enacted (signed by the Governor on July 1, 2025).

Key provisions

Clarifies the process and requirements for accessing nonformulary drugs that are used to treat serious mental illness (SMI).

Eliminates the statutory requirement that a health plan must provide access to a clinically appropriate drug that is not otherwise covered by the plan. In other words, carriers are no longer required by that provision to cover clinically appropriate drugs outside the plan’s coverage.

Requires a carrier to approve prior authorization for an equivalent nonformulary drug when:

the formulary drug is in shortage, and
there is no formulary equivalent available.

Committee Amendment: The bill passed with Committee Amendment “A” (S‑166) (adopted and engrossed).

Who is affected

Enrollees in commercial and public health plans (including members of the State Employee Health Plan) who need access to nonformulary drugs, especially those treating serious mental illness.

Health insurers and other carriers that maintain drug formularies and prior‑authorization processes.

Pharmacists and prescribers who navigate formulary restrictions and shortages.

Fiscal and practical impact

The fiscal notes (approved 05/14/25 and 05/29/25) indicate a potential increase in costs to the State Employee Health Plan due to the requirement to approve equivalent nonformulary drugs during shortages.

A precise fiscal estimate is not provided because impacts depend on unpredictable factors (timing and scope of drug shortages, number of affected members, utilization patterns).

Removing the prior requirement to provide access to clinically appropriate, noncovered drugs reduces an explicit carrier obligation but the net fiscal effect is uncertain given the shortage‑related approval requirement.

Legislative timeline (selected)

Introduced: March 14, 2025; referred to the Committee on Health Coverage, Insurance and Financial Services.

Committee work: Voted OTP‑AM; Committee Amendment “A” adopted.

Passed both chambers and enacted: Passed to be Enacted (June 2 & June 25, 2025); Signed by Governor (July 1, 2025).

For the full statutory text and amendment language, consult the Maine Legislature’s bill resources (LD 1100, LR 629, 132nd Legislature).

Bill