2015 -- H 5605

========

LC001289

========

     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2015

____________

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     

     Introduced By: Representatives O`Grady, Ackerman, and Keable

     Date Introduced: February 25, 2015

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

1

     SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness

2

Insurance Policies" is hereby amended by adding thereto the following section:

3

     27-18-82. Step therapy protocol. – (a) Legislative findings and declaration. The general

4

assembly makes the following findings:

5

     (1) Health insurance plans are increasingly making use of step therapy policies under

6

which health plan members are required to try one or more prescription drugs before coverage is

7

provided for a drug recommended by the patient's health care provider.

8

     (2) Such step therapy policies, where they are based on well-developed scientific

9

standards and administered in a flexible manner that takes into account the individual needs of

10

patients, can play an important role in controlling health care costs.

11

     (3) In some cases, requiring a patient to follow a step therapy policy may have adverse

12

and even dangerous consequences for the patient who may either not realize a benefit from taking

13

a prescription drug or may suffer harm from taking the wrong drug.

14

     (4) Without uniform policies across the state on step therapy, patients may not receive the

15

best and most appropriate treatment.

16

     (5) It is imperative that step therapy policies throughout the state preserve physicians'

17

rights to make treatment decisions in the best interest of their patients.

18

     (6) Based on these findings, the general assembly declares it a matter of public interest

19

that it require health plans to base step therapy requirements on appropriate clinical practice

 

1

guidelines developed by professional medical societies with expertise in the condition or

2

conditions under consideration; that patients be exempt from step therapy requirements when

3

impracticable or otherwise not in the best interest of the patients; and that patients and prescribers

4

have access to a transparent and independent process for requesting an exception of step therapy

5

requirements when appropriate.

6

     (b) Definitions. As used in this section:

7

     (1) "Clinical practice guidelines" means a systematically developed statement to assist

8

practitioner and patient decisions about appropriate health care for specific clinical circumstances.

9

     (2) "Clinical review criteria" means the written screening procedures, decision abstracts,

10

clinical protocols and practice guidelines used by an insurer or health plan to determine the

11

medical necessity and appropriateness of health care services.

12

     (3) "Step therapy protocol" means a protocol or program that establishes the specific

13

sequence in which prescription drugs for a specified medical condition and medically appropriate

14

for a particular patient are to be prescribed and paid for by a health plan.

15

     (4) "Step therapy override determination" means a determination as to whether step

16

therapy should apply in a particular situation, or whether the step therapy protocol should be

17

overridden in favor of immediate coverage of the patient's and/or prescriber's preferred drug.

18

This determination is based on a review of the patient's and/or prescriber's request for an override,

19

along with supporting rationale and documentation.

20

     (5) "Utilization review organization" means an entity that conducts utilization review,

21

other than a health carrier performing utilization review for its own health benefit plans.

22

     (c) Clinical review criteria, requirements and restrictions. Clinical review criteria used to

23

establish step therapy protocols shall be based on clinical practice guidelines:

24

     (1) Independently developed by a professional medical society with expertise in the

25

medical condition, or conditions, for which coverage decisions said criteria will be applied; and

26

     (2) That recommend drugs be taken in the specific sequence required by the step therapy

27

protocol.

28

     (d) Exceptions process transparency.

29

     (1) Exceptions process. When coverage of medications for the treatment of any medical

30

condition are restricted for use by an insurer, health plan, or utilization review organization via a

31

step therapy protocol, the patient and prescribing practitioner shall have access to a clear and

32

convenient process to request a step therapy exception determination. An insurer, health plan, or

33

utilization review organization may use its existing medical exceptions process to satisfy this

34

requirement. The process shall be disclosed to the patient and health care providers, including

 

LC001289 - Page 2 of 14

1

documenting and making it easily accessible on the insurer's or health plan's website.

2

     (2) Exceptions. An exception request shall be expeditiously granted if:

3

     (i) The required drug is contraindicated or will likely cause an adverse reaction or

4

physical or mental harm to the patient;

5

     (ii) The required drug is expected to be ineffective based on the known relevant physical

6

or mental characteristics of the insured/patient and the known characteristics of the drug regimen;

7

     (iii) The enrollee has tried the step therapy required drug while under their current or a

8

previous health plan, or another drug in the same pharmacologic class or with the same

9

mechanism of action and such drugs were discontinued due to lack of efficacy or effectiveness,

10

diminished effect, or an adverse event; or

11

     (iv) The patient is stable on a drug recommended by their health care provider for the

12

medical condition under consideration, based on, but not limited to, a trial with medication

13

samples or a prescription filled at a pharmacy.

14

     (3) Effect of exception. Upon the granting of an exception request, the insurer, health

15

plan, utilization review organization, or other entity shall authorize dispensation of and coverage

16

for the drug prescribed by the enrollee's treating health care provider, provided such drug is a

17

covered drug under such policy or contract.

18

     (4) Limitations. This section shall not be construed to prevent:

19

     (i) An insurer, health plan, or utilization review organization from requiring an enrollee

20

try an AB-rated generic equivalent prior to providing reimbursement for the equivalent branded

21

drug;

22

     (ii) A health care provider from prescribing a drug he or she determines is medically

23

appropriate.

24

     (e) Regulations. Notwithstanding any general or special law to the contrary, the division

25

of insurance shall promulgate any regulations necessary to enforce this section.

26

     SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service

27

Corporations" is hereby amended by adding thereto the following section:

28

     27-19-73. Step therapy drug protocol. -- (a) Legislative findings and declaration. The

29

general assembly makes the following findings:

30

     (1) Health insurance plans are increasingly making use of step therapy policies under

31

which health plan members are required to try one or more prescription drugs before coverage is

32

provided for a drug recommended by the patient's health care provider.

33

     (2) Such step therapy policies, where they are based on well-developed scientific

34

standards and administered in a flexible manner that takes into account the individual needs of

 

LC001289 - Page 3 of 14

1

patients, can play an important role in controlling health care costs.

2

     (3) In some cases, requiring a patient to follow a step therapy policy may have adverse

3

and even dangerous consequences for the patient who may either not realize a benefit from taking

4

a prescription drug or may suffer harm from taking the wrong drug.

5

     (4) Without uniform policies across the state on step therapy, patients may not receive the

6

best and most appropriate treatment.

7

     (5) It is imperative that step therapy policies throughout the state preserve physicians'

8

rights to make treatment decisions in the best interest of their patients.

9

     (6) Based on these findings, the general assembly declares it a matter of public interest

10

that it require health plans to base step therapy requirements on appropriate clinical practice

11

guidelines developed by professional medical societies with expertise in the condition or

12

conditions under consideration; that patients be exempt from step therapy requirements when

13

impracticable or otherwise not in the best interest of the patients; and that patients and prescribers

14

have access to a transparent and independent process for requesting an exception of step therapy

15

requirements when appropriate.

16

     (b) Definitions. As used in this section:

17

     (1) "Clinical practice guidelines" means a systematically developed statement to assist

18

practitioner and patient decisions about appropriate health care for specific clinical circumstances.

19

     (2) "Clinical review criteria" means the written screening procedures, decision abstracts,

20

clinical protocols and practice guidelines used by an insurer or health plan to determine the

21

medical necessity and appropriateness of health care services.

22

     (3) "Step therapy protocol" means a protocol or program that establishes the specific

23

sequence in which prescription drugs for a specified medical condition and medically appropriate

24

for a particular patient are to be prescribed and paid for by a health plan.

25

     (4) "Step therapy override determination" means a determination as to whether step

26

therapy should apply in a particular situation, or whether the step therapy protocol should be

27

overridden in favor of immediate coverage of the patient's and/or prescriber's preferred drug.

28

This determination is based on a review of the patient's and/or prescriber's request for an override,

29

along with supporting rationale and documentation.

30

     (5) "Utilization review organization" means an entity that conducts utilization review,

31

other than a health carrier performing utilization review for its own health benefit plans.

32

     (c) Clinical review criteria. Requirements and restrictions. Clinical review criteria used to

33

establish step therapy protocols shall be based on clinical practice guidelines:

34

     (1) Independently developed by a professional medical society with expertise in the

 

LC001289 - Page 4 of 14

1

medical condition, or conditions, for which coverage decisions said criteria will be applied; and

2

     (2) That recommend drugs be taken in the specific sequence required by the step therapy

3

protocol.

4

     (d) Exceptions process transparency.

5

     (1) Exceptions process. When coverage of medications for the treatment of any medical

6

condition are restricted for use by an insurer, health plan, or utilization review organization via a

7

step therapy protocol, the patient and prescribing practitioner shall have access to a clear and

8

convenient process to request a step therapy exception determination. An insurer, health plan, or

9

utilization review organization may use its existing medical exceptions process to satisfy this

10

requirement. The process shall be disclosed to the patient and health care providers, including

11

documenting and making it easily accessible on the insurer's or health plan's website.

12

     (2) Exceptions. An exception request shall be expeditiously granted if:

13

     (i) The required drug is contraindicated or will likely cause an adverse reaction or

14

physical or mental harm to the patient;

15

     (ii) The required drug is expected to be ineffective based on the known relevant physical

16

or mental characteristics of the insured/patient and the known characteristics of the drug regimen;

17

     (iii) The enrollee has tried the step therapy required drug while under their current or a

18

previous health plan, or another drug in the same pharmacologic class or with the same

19

mechanism of action and such drugs were discontinued due to lack of efficacy or effectiveness,

20

diminished effect, or an adverse event; or

21

     (iv) The patient is stable on a drug recommended by their health care provider for the

22

medical condition under consideration, based on, but not limited to, a trial with medication

23

samples or a prescription filled at a pharmacy.

24

     (3) Effect of exception. Upon the granting of an exception request, the insurer, health

25

plan, utilization review organization, or other entity shall authorize dispensation of and coverage

26

for the drug prescribed by the enrollee's treating health care provider, provided such drug is a

27

covered drug under such policy or contract.

28

     (4) Limitations. This section shall not be construed to prevent:

29

     (i) An insurer, health plan, or utilization review organization from requiring an enrollee

30

try an AB-rated generic equivalent prior to providing reimbursement for the equivalent branded

31

drug;

32

     (ii) A health care provider from prescribing a drug he or she determines is medically

33

appropriate.

34

     (e) Regulations. Notwithstanding any general or special law to the contrary, the division

 

LC001289 - Page 5 of 14

1

of insurance shall promulgate any regulations necessary to enforce this section.

2

     SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service

3

Corporations" is hereby amended by adding thereto the following section:

4

     27-20-69. Step therapy protocol. -- (a) Legislative findings and declaration. The general

5

assembly makes the following findings:

6

     (1) Health insurance plans are increasingly making use of step therapy policies under

7

which health plan members are required to try one or more prescription drugs before coverage is

8

provided for a drug recommended by the patient's health care provider.

9

     (2) Such step therapy policies, where they are based on well-developed scientific

10

standards and administered in a flexible manner that takes into account the individual needs of

11

patients, can play an important role in controlling health care costs.

12

     (3) In some cases, requiring a patient to follow a step therapy policy may have adverse

13

and even dangerous consequences for the patient who may either not realize a benefit from taking

14

a prescription drug or may suffer harm from taking the wrong drug.

15

     (4) Without uniform policies across the state on step therapy, patients may not receive the

16

best and most appropriate treatment.

17

     (5) It is imperative that step therapy policies throughout the state preserve physicians'

18

rights to make treatment decisions in the best interest of their patients.

19

     (6) Based on these findings, the general assembly declares it a matter of public interest

20

that it require health plans to base step therapy requirements on appropriate clinical practice

21

guidelines developed by professional medical societies with expertise in the condition or

22

conditions under consideration; that patients be exempt from step therapy requirements when

23

impracticable or otherwise not in the best interest of the patients; and that patients and prescribers

24

have access to a transparent and independent process for requesting an exception of step therapy

25

requirements when appropriate.

26

     (b) Definitions. As used in this section:

27

     (1) "Clinical practice guidelines" means a systematically developed statement to assist

28

practitioner and patient decisions about appropriate health care for specific clinical circumstances.

29

     (2) "Clinical review criteria" means the written screening procedures, decision abstracts,

30

clinical protocols and practice guidelines used by an insurer or health plan to determine the

31

medical necessity and appropriateness of health care services.

32

     (3) "Step therapy protocol" means a protocol or program that establishes the specific

33

sequence in which prescription drugs for a specified medical condition and medically appropriate

34

for a particular patient are to be prescribed and paid for by a health plan.

 

LC001289 - Page 6 of 14

1

     (4) "Step therapy override determination" means a determination as to whether step

2

therapy should apply in a particular situation, or whether the step therapy protocol should be

3

overridden in favor of immediate coverage of the patient's and/or prescriber's preferred drug.

4

This determination is based on a review of the patient's and/or prescriber's request for an override,

5

along with supporting rationale and documentation.

6

     (5) "Utilization review organization" means an entity that conducts utilization review,

7

other than a health carrier performing utilization review for its own health benefit plans.

8

     (c) Clinical review criteria. Requirements and restrictions. Clinical review criteria used to

9

establish step therapy protocols shall be based on clinical practice guidelines:

10

     (1) Independently developed by a professional medical society with expertise in the

11

medical condition, or conditions, for which coverage decisions said criteria will be applied; and

12

     (2) That recommend drugs be taken in the specific sequence required by the step therapy

13

protocol.

14

     (d) Exceptions process transparency.

15

     (1) Exceptions process. When coverage of medications for the treatment of any medical

16

condition are restricted for use by an insurer, health plan, or utilization review organization via a

17

step therapy protocol, the patient and prescribing practitioner shall have access to a clear and

18

convenient process to request a step therapy exception determination. An insurer, health plan, or

19

utilization review organization may use its existing medical exceptions process to satisfy this

20

requirement. The process shall be disclosed to the patient and health care providers, including

21

documenting and making it easily accessible on the insurer's or health plan's website.

22

     (2) Exceptions. An exception request shall be expeditiously granted if:

23

     (i) The required drug is contraindicated or will likely cause an adverse reaction or

24

physical or mental harm to the patient;

25

     (ii) The required drug is expected to be ineffective based on the known relevant physical

26

or mental characteristics of the insured/patient and the known characteristics of the drug regimen;

27

     (iii) The enrollee has tried the step therapy required drug while under their current or a

28

previous health plan, or another drug in the same pharmacologic class or with the same

29

mechanism of action and such drugs were discontinued due to lack of efficacy or effectiveness,

30

diminished effect, or an adverse event; or

31

     (iv) The patient is stable on a drug recommended by their health care provider for the

32

medical condition under consideration, based on, but not limited to, a trial with medication

33

samples or a prescription filled at a pharmacy.

34

     (3) Effect of exception. Upon the granting of an exception request, the insurer, health

 

LC001289 - Page 7 of 14

1

plan, utilization review organization, or other entity shall authorize dispensation of and coverage

2

for the drug prescribed by the enrollee's treating health care provider, provided such drug is a

3

covered drug under such policy or contract.

4

     (4) Limitations. This section shall not be construed to prevent:

5

     (i) An insurer, health plan, or utilization review organization from requiring an enrollee

6

try an AB-rated generic equivalent prior to providing reimbursement for the equivalent branded

7

drug;

8

     (ii) A health care provider from prescribing a drug he or she determines is medically

9

appropriate.

10

     (e) Regulations. Notwithstanding any general or special law to the contrary, the division

11

of insurance shall promulgate any regulations necessary to enforce this section.

12

     SECTION 4. Chapter 27-20.1 of the General Laws entitled "Nonprofit Dental Service

13

Corporations" is hereby amended by adding thereto the following section:

14

     27-20.1-23. Step therapy protocol. – (a) Legislative findings and declaration. The

15

general assembly makes the following findings:

16

     (1) Health insurance plans are increasingly making use of step therapy policies under

17

which health plan members are required to try one or more prescription drugs before coverage is

18

provided for a drug recommended by the patient's health care provider.

19

     (2) Such step therapy policies, where they are based on well-developed scientific

20

standards and administered in a flexible manner that takes into account the individual needs of

21

patients, can play an important role in controlling health care costs.

22

     (3) In some cases, requiring a patient to follow a step therapy policy may have adverse

23

and even dangerous consequences for the patient who may either not realize a benefit from taking

24

a prescription drug or may suffer harm from taking the wrong drug.

25

     (4) Without uniform policies across the state on step therapy, patients may not receive the

26

best and most appropriate treatment.

27

     (5) It is imperative that step therapy policies throughout the state preserve physicians'

28

rights to make treatment decisions in the best interest of their patients.

29

     (6) Based on these findings, the general assembly declares it a matter of public interest

30

that it require health plans to base step therapy requirements on appropriate clinical practice

31

guidelines developed by professional medical societies with expertise in the condition or

32

conditions under consideration; that patients be exempt from step therapy requirements when

33

impracticable or otherwise not in the best interest of the patients; and that patients and prescribers

34

have access to a transparent and independent process for requesting an exception of step therapy

 

LC001289 - Page 8 of 14

1

requirements when appropriate.

2

     (b) Definitions. As used in this section:

3

     (1) "Clinical practice guidelines" means a systematically developed statement to assist

4

practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.

5

     (2) "Clinical review criteria" means the written screening procedures, decision abstracts,

6

clinical protocols and practice guidelines used by an insurer or health plan to determine the

7

medical necessity and appropriateness of healthcare services.

8

     (3) "Step therapy protocol" means a protocol or program that establishes the specific

9

sequence in which prescription drugs for a specified medical condition and medically appropriate

10

for a particular patient are to be prescribed and paid for by a health plan.

11

     (4) "Step therapy override determination" means a determination as to whether step

12

therapy should apply in a particular situation, or whether the step therapy protocol should be

13

overridden in favor of immediate coverage of the patient's and/or prescriber's preferred drug.

14

This determination is based on a review of the patient's and/or prescriber's request for an override,

15

along with supporting rationale and documentation.

16

     (5) "Utilization review organization" means an entity that conducts utilization review,

17

other than a health carrier performing utilization review for its own health benefit plans.

18

     (c) Clinical review criteria. Requirements and restrictions. Clinical review criteria used to

19

establish step therapy protocols shall be based on clinical practice guidelines:

20

     (1) Independently developed by a professional medical society with expertise in the

21

medical condition, or conditions, for which coverage decisions said criteria will be applied; and

22

     (2) That recommend drugs be taken in the specific sequence required by the step therapy

23

protocol.

24

     (d) Exceptions process transparency.

25

     (1) Exceptions process. When coverage of medications for the treatment of any medical

26

condition are restricted for use by an insurer, health plan, or utilization review organization via a

27

step therapy protocol, the patient and prescribing practitioner shall have access to a clear and

28

convenient process to request a step therapy exception determination. An insurer, health plan, or

29

utilization review organization may use its existing medical exceptions process to satisfy this

30

requirement. The process shall be disclosed to the patient and health care providers, including

31

documenting and making it easily accessible on the insurer's or health plan's website.

32

     (2) Exceptions. An exception request shall be expeditiously granted if:

33

     (i) The required drug is contraindicated or will likely cause an adverse reaction or

34

physical or mental harm to the patient;

 

LC001289 - Page 9 of 14

1

     (ii) The required drug is expected to be ineffective based on the known relevant physical

2

or mental characteristics of the insured/patient and the known characteristics of the drug regimen;

3

     (iii) The enrollee has tried the step therapy required drug while under their current or a

4

previous health plan, or another drug in the same pharmacologic class or with the same

5

mechanism of action and such drugs were discontinued due to lack of efficacy or effectiveness,

6

diminished effect, or an adverse event; or

7

     (iv) The patient is stable on a drug recommended by their health care provider for the

8

medical condition under consideration, based on, but not limited to, a trial with medication

9

samples or a prescription filled at a pharmacy.

10

     (3) Effect of exception. Upon the granting of an exception request, the insurer, health

11

plan, utilization review organization, or other entity shall authorize dispensation of and coverage

12

for the drug prescribed by the enrollee's treating health care provider, provided such drug is a

13

covered drug under such policy or contract.

14

     (4) Limitations. This section shall not be construed to prevent:

15

     (i) An insurer, health plan, or utilization review organization from requiring an enrollee

16

try an AB-rated generic equivalent prior to providing reimbursement for the equivalent branded

17

drug;

18

     (ii) A health care provider from prescribing a drug he or she determines is medically

19

appropriate.

20

     (e) Regulations. Notwithstanding any general or special law to the contrary, the division

21

of insurance shall promulgate any regulations necessary to enforce this section.

22

     SECTION 5. Chapter 27-41 of the General Laws entitled "Health Maintenance

23

Organizations" is hereby amended by adding thereto the following section:

24

     27-41-86. Step therapy protocol. -- (a) Legislative findings and declaration. The general

25

assembly makes the following findings:

26

     (1) Health insurance plans are increasingly making use of step therapy policies under

27

which health plan members are required to try one or more prescription drugs before coverage is

28

provided for a drug recommended by the patient's health care provider.

29

     (2) Such step therapy policies, where they are based on well-developed scientific

30

standards and administered in a flexible manner that takes into account the individual needs of

31

patients, can play an important role in controlling health care costs.

32

     (3) In some cases, requiring a patient to follow a step therapy policy may have adverse

33

and even dangerous consequences for the patient who may either not realize a benefit from taking

34

a prescription drug or may suffer harm from taking the wrong drug.

 

LC001289 - Page 10 of 14

1

     (4) Without uniform policies across the state on step therapy, patients may not receive the

2

best and most appropriate treatment.

3

     (5) It is imperative that step therapy policies throughout the state preserve physicians'

4

rights to make treatment decisions in the best interest of their patients.

5

     (6) Based on these findings, the general assembly declares it a matter of public interest

6

that it require health plans to base step therapy requirements on appropriate clinical practice

7

guidelines developed by professional medical societies with expertise in the condition or

8

conditions under consideration; that patients be exempt from step therapy requirements when

9

impracticable or otherwise not in the best interest of the patients; and that patients and prescribers

10

have access to a transparent and independent process for requesting an exception of step therapy

11

requirements when appropriate.

12

     (b) Definitions. As used in this section:

13

     (1) "Clinical practice guidelines" means a systematically developed statement to assist

14

practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.

15

     (2) "Clinical review criteria" means the written screening procedures, decision abstracts,

16

clinical protocols and practice guidelines used by an insurer or health plan to determine the

17

medical necessity and appropriateness of healthcare services.

18

     (3) "Step therapy protocol" means a protocol or program that establishes the specific

19

sequence in which prescription drugs for a specified medical condition and medically appropriate

20

for a particular patient are to be prescribed and paid for by a health plan.

21

     (4) "Step therapy override determination" means a determination as to whether step

22

therapy should apply in a particular situation, or whether the step therapy protocol should be

23

overridden in favor of immediate coverage of the patient's and/or prescriber's preferred drug.

24

This determination is based on a review of the patient's and/or prescriber's request for an override,

25

along with supporting rationale and documentation.

26

     (5) "Utilization review organization" means an entity that conducts utilization review,

27

other than a health carrier performing utilization review for its own health benefit plans.

28

     (c) Clinical review criteria. Requirements and restrictions. Clinical review criteria used to

29

establish step therapy protocols shall be based on clinical practice guidelines:

30

     (1) Independently developed by a professional medical society with expertise in the

31

medical condition, or conditions, for which coverage decisions said criteria will be applied; and

32

     (2) That recommend drugs be taken in the specific sequence required by the step therapy

33

protocol.

34

     (d) Exceptions process transparency.

 

LC001289 - Page 11 of 14

1

     (1) Exceptions process. When coverage of medications for the treatment of any medical

2

condition are restricted for use by an insurer, health plan, or utilization review organization via a

3

step therapy protocol, the patient and prescribing practitioner shall have access to a clear and

4

convenient process to request a step therapy exception determination. An insurer, health plan, or

5

utilization review organization may use its existing medical exceptions process to satisfy this

6

requirement. The process shall be disclosed to the patient and health care providers, including

7

documenting and making it easily accessible on the insurer's or health plan's website.

8

     (2) Exceptions. An exception request shall be expeditiously granted if:

9

     (i) The required drug is contraindicated or will likely cause an adverse reaction or

10

physical or mental harm to the patient;

11

     (ii) The required drug is expected to be ineffective based on the known relevant physical

12

or mental characteristics of the insured/patient and the known characteristics of the drug regimen;

13

     (iii) The enrollee has tried the step therapy required drug while under their current or a

14

previous health plan, or another drug in the same pharmacologic class or with the same

15

mechanism of action and such drugs were discontinued due to lack of efficacy or effectiveness,

16

diminished effect, or an adverse event; or

17

     (iv) The patient is stable on a drug recommended by their health care provider for the

18

medical condition under consideration, based on, but not limited to, a trial with medication

19

samples or a prescription filled at a pharmacy.

20

     (3) Effect of exception. Upon the granting of an exception request, the insurer, health

21

plan, utilization review organization, or other entity shall authorize dispensation of and coverage

22

for the drug prescribed by the enrollee's treating health care provider, provided such drug is a

23

covered drug under such policy or contract.

24

     (4) Limitations. This section shall not be construed to prevent:

25

     (i) An insurer, health plan, or utilization review organization from requiring an enrollee

26

try an AB-rated generic equivalent prior to providing reimbursement for the equivalent branded

27

drug;

28

     (ii) A health care provider from prescribing a drug he or she determines is medically

29

appropriate.

30

     (e) Regulations. Notwithstanding any general or special law to the contrary, the division

31

of insurance shall promulgate any regulations necessary to enforce this section.

32

 

LC001289 - Page 12 of 14

1

     SECTION 6. This act shall take effect upon passage and shall apply to health insurance

2

policies and health benefit plans delivered, issued for delivery, or renewed on or after January 1,

3

2016.

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LC001289 - Page 13 of 14

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

***

1

     This act would require that a step therapy protocol be included in all health care

2

insurance policies and health insurance plans.

3

     This act would take effect upon passage and would apply to health insurance policies and

4

health benefit plans delivered, issued for delivery, or renewed on or after January 1, 2016.

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LC001289

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LC001289 - Page 14 of 14