SS/HCS/HB 2029 - Under this act, patients and their health care providers shall have access to a clear, convenient, and readily accessible process to request a step therapy override exception determination if coverage of a prescription drug for the treatment of a medical condition is restricted for use via a step therapy protocol by a health carrier, health benefit plan, or utilization review organization. A "step therapy protocol" is a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition and medically appropriate for a particular patient are to be prescribed and covered by a health carrier or health benefit plan. A "step therapy override exception determination" is a determination as to whether a step therapy protocol should apply in a particular situation or whether such protocol should be overridden in favor of immediate coverage of the health care provider's preferred prescription drug.
Under this act, a step therapy override exception shall be granted if the patient has tried the step therapy-required prescription drugs while under their current or previous health insurance or health benefit plan and such prescription drugs were discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event. The provisions of this act shall not be construed to prevent a health carrier, health benefit plan, or utilization review organization from requiring a patient to try a generic equivalent or other brand name drug prior to providing coverage for the requested prescription drug or to prevent a health care provider from prescribing a prescription drug he or she determines is medically appropriate.
The Department of Insurance, Financial Institutions and Professional Registration shall enforce the provisions of this act. This act shall apply to health insurance and health benefit plans delivered, issued for delivery, or renewed on or after January 1, 2018.
This act is similar to HB 932 (2015).