Step therapy protocols for prescription drug coverage and requiring the exercise of rule-making authority

What it does

Summary by the Legislative Reference Bureau, the Legislature's nonpartisan drafting office. It's their wording, not ours.

This bill sets specifications on the development and use of and exceptions to step therapy protocols for prescription drug coverage. A step therapy protocol, as defined in the bill, is a protocol that establishes the specific sequence in which prescription drugs for a specified medical condition that are medically appropriate for a particular patient are covered by a policy or plan. When establishing a step therapy protocol, an insurer, pharmacy benefit manager, or utilization review organization must use clinical review criteria based on clinical practice guidelines that meet certain criteria specified in the bill, including development and endorsement of the guidelines either by a multidisciplinary panel of experts that manages conflicts of interest among its members or, in the absence of a multidisciplinary panel, based on peer reviewed publications. The bill requires the insurer, pharmacy benefit manager, or utilization review organization to consider the needs of atypical patient populations and diagnoses when establishing the clinical review criteria.

If an insurer, pharmacy benefit manager, or utilization review organization restricts the coverage of a prescription drug through a step therapy protocol, the insurer, pharmacy benefit manager, or utilization review organization must provide access to a process to request an exception to the step therapy protocol, though an existing medical exceptions process may be used to satisfy this requirement. The insurer, pharmacy benefit manager, or utilization review organization must expeditiously grant an exception to the step therapy protocol under certain circumstances specified in the bill, including when the drug is contraindicated for the patient or will likely cause an adverse reaction for the patient; the drug is expected to be ineffective; the patient tried the drug previously and discontinued its use due to adverse event or ineffectiveness; use of the drug is not in the patient's best interest;

Who's behind it

15 senators are its authors⁠. 11 are Republicans and 4 are Democrats.

44 more lawmakers signed on in support⁠.

Versions and amendments

Every text the Legislature printed for this bill, including proposed changes. Each opens on the Legislature's site.

• Amendment Histories
• LC Amendment Memo