Bill(s)
2019 Act 12 sets requirements insurers must follow when they use a step therapy protocol, provides that a step therapy protocol must use clinical review criteria based on clinical practice guidelines, and requires the following exceptions to be granted for prescription drug coverage:
- The patient previously tried the drug or a similar drug and its use by the patient was discontinued under circumstances described in the act.
- The drug is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug regimen.
- The required prescription drug is not in the best interest of the patient, based on medical necessity.
- The patient is stable on a prescription drug selected by their health care provider.
- The drug is contraindicated or will likely cause an adverse reaction by or physical or mental harm to the patient.
Finally, the law outlines an appeal process and would give insurers three business days to deny the request or the exception is granted.
The act takes effect on the first day of the fourth month beginning after publication (November 1, 2019). Additionally, for policies and plans containing provisions inconsistent with this act, the act first applies to policy or plan years beginning on January 1, 2020.
Sponsors
Status
2019 Session - Enacted Into Law
Other
Please contact Tarna Hunter, ETF’s Government Relations Director, if you have any questions.