• Requires step therapy exceptions to occur within twenty-four (24) hours in an urgent health care situation and seventy-two (72) hours in a non-urgent healthcare situation.

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• Permits a prescriber to override step therapy with an exception when:

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1.  The required drug is contraindicated.

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2. The required drug has been tried and failed previously.

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3. The required drug will not be effective or if the patient is already stable on another drug.

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4. Requiring patients to follow a step therapy protocol may have adverse and even dangerous consequences for the patient.

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5. Using the protocol may cause patients to not receive the best treatment deemed by their health care provider to meet their medical needs.

 

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• Requires health insurance plans to incorporate step therapy exception processes in their pre-authorization applications.

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• Prohibits insurers from requiring insured patients from having to fail on a prescription medication more than once.

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• In circumstances where an insured is changing health insurance plans, the new plan may not require the patient to repeat step therapy when that person is already being treated for a medical condition with a prescription drug provided that is considered safe and effective for the patient’s condition.

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• When a health insurance plan changes formulary design, the plan cannot limit or exclude coverage for a drug previously approved for coverage by the plan for a specific medical condition.

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• Ensures that health plans step therapy protocols be based on well-developed scientific, practice standards and the physicians’ knowledge of the patient’s condition and drug regime and administered in a flexible manner that takes into account the medical individual needs of patients.