Effective 28 Aug 2016

376.2034. Restriction on step therapy protocol, patient to have access to override exception determination — procedure. — 1. If coverage of a prescription drug for the treatment of any medical condition is restricted for use by a health carrier, health benefit plan, or utilization review organization via a step therapy protocol, a patient, through his or her health care provider, shall have access to a clear, convenient, and readily accessible process to request a step therapy override exception determination. A health carrier, health benefit plan, or utilization review organization may use its existing medical exceptions process to satisfy this requirement. The process shall be disclosed to the patient and health care provider, which shall include the necessary documentation needed to process such request and be made available on the health carrier plan or health benefit plan website.

2. A step therapy override exception determination shall be granted if the patient has tried the step therapy required prescription drugs while under his or her 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. Pharmacy drug samples shall not be considered trial and failure of a preferred prescription drug in lieu of trying the step therapy required prescription drug.

3. The health carrier, health benefit plan, or utilization review organization may request relevant documentation from the patient or provider to support the override exception request.

4. Upon the granting of a step therapy override exception request, the health carrier, health benefit plan, or utilization review organization shall authorize dispensation of and coverage for the prescription drug prescribed by the patient's treating health care provider, provided such drug is a covered drug under such policy or contract.

5. This section shall not be construed to prevent:

(1) 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

(2) A health care provider from prescribing a prescription drug he or she determines is medically appropriate.

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(L. 2016 H.B. 2029)