This bill requires a group health plan to establish an exception to medication step-therapy protocol in specified cases. A medication step-therapy protocol establishes a specific sequence in which prescription drugs are covered by a group health plan or a health insurance issuer.
A request for such an exception to the protocol must be granted if (1) the treatment is expected to be ineffective, (2) the treatment will cause or is likely to cause an adverse reaction to the individual, (3) the treatment is expected to decrease the individual's ability either to perform daily activities or occupational responsibilities or adhere to the treatment plan, (4) the individual is stable based on the prescription drugs already selected, or (5) there are other medical reasons that warrant withholding the treatment.
The bill requires a group health plan to implement and make readily available a clear process for an individual to request an exception to the protocol. Requests must be granted no later than three days after receipt of the request. In certain cases where the life, health, and ability of the individual are jeopardized by the protocol, the request shall be granted no later than 24 hours after receipt of the request.
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