(a) The Commissioner of Social Services may establish a step therapy program for prescription drugs in the Medicaid program. The commissioner may condition payment for such drugs on a requirement that the drug prescribed be from the preferred drug list established pursuant to section 17b-274d prior to any other drug being prescribed, provided any step therapy program shall: (1) Require that the patient try and fail on only one prescribed drug on the preferred drug list before another drug can be prescribed and eligible for payment; (2) not apply to any mental health–related drugs; and (3) require that the prescribing practitioner, when medications for the treatment of any medical condition are restricted due to the step therapy program, has access to a clear and convenient process to expeditiously request an override of such restriction from the Department of Social Services. The department shall expeditiously grant an override of such restriction whenever the prescribing practitioner demonstrates that: (A) The preferred treatment required under step therapy has been ineffective in the treatment of the patient's medical condition in the past; (B) the drug regimen required under the step therapy program is expected to be ineffective based on the known relevant physical or mental characteristics of the patient and the known characteristics of the drug regimen; (C) the preferred treatment required under the step therapy program will cause or will likely cause an adverse reaction or other physical harm to the patient; or (D) it is in the best interest of the patient to provide the recommended drug regimen based on medical necessity.

(b) The duration of any step therapy program requirement shall not be longer than a period of thirty days, after which time the prescribing practitioner may deem such treatment as clinically ineffective for the patient. When the prescribing practitioner deems the treatment to be clinically ineffective, the drug prescribed and recommended by the practitioner shall be dispensed and covered under the Medicaid program.

(P.A. 13-234, S. 126.)

History: P.A. 13-234 effective July 1, 2013.