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General Assembly Raised Bill No. 5275
February Session, 2022
LCO No. 1825
Referred to Committee on PUBLIC HEALTH
Introduced by:
(PH)
AN ACT PROHIBITING CERTAIN HEALTH CARRIERS FROM
REQUIRING STEP THERAPY FOR PRESCRIPTION DRUGS USED TO
TREAT MENTAL OR BEHAVIORAL HEALTH CONDITIONS.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Section 38a-510 of the general statutes is repealed and the 1
following is substituted in lieu thereof (Effective January 1, 2023): 2
(a) No insurance company, hospital service corporation, medical 3
service corporation, health care center or other entity delivering, issuing 4
for delivery, renewing, amending or continuing an individual health 5
insurance policy or contract that provides coverage for prescription 6
drugs may: 7
(1) Require any person covered under such policy or contract to 8
obtain prescription drugs from a mail order pharmacy as a condition of 9
obtaining benefits for such drugs; or 10
(2) Require, if such insurance company, hospital service corporation, 11
medical service corporation, health care center or other entity uses step 12
therapy for such drugs, the use of step therapy for (A) any prescribed 13 Raised Bill No. 5275
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drug for longer than sixty days, [or] (B) a prescribed drug for cancer 14
treatment for an insured who has been diagnosed with stage IV 15
metastatic cancer, provided such prescribed drug is in compliance with 16
approved federal Food and Drug Administration indications, or (C) a 17
prescribed drug for treatment of a mental or behavioral health 18
condition, provided such prescribed drug is in compliance with 19
approved federal Food and Drug Administration indications. 20
(3) At the expiration of the time period specified in subparagraph (A) 21
of subdivision (2) of this subsection or for a prescribed drug described 22
in subparagraph (B) or (C) of subdivision (2) of this subsection, an 23
insured's treating health care provider may deem such step therapy 24
drug regimen clinically ineffective for the insured, at which time the 25
insurance company, hospital service corporation, medical service 26
corporation, health care center or other entity shall authorize 27
dispensation of and coverage for the drug prescribed by the insured's 28
treating health care provider, provided such drug is a covered drug 29
under such policy or contract. If such provider does not deem such step 30
therapy drug regimen clinically ineffective or has not requested an 31
override pursuant to subdivision (1) of subsection (b) of this section, 32
such drug regimen may be continued. For purposes of this section, "step 33
therapy" means a protocol or program that establishes the specific 34
sequence in which prescription drugs for a specified medical condition 35
are to be prescribed. 36
(b) (1) Notwithstanding the sixty-day period set forth in subdivision 37
(2) of subsection (a) of this section, each insurance company, hospital 38
service corporation, medical service corporation, health care center or 39
other entity that uses step therapy for such prescription drugs shall 40
establish and disclose to its health care providers a process by which an 41
insured's treating health care provider may request at any time an 42
override of the use of any step therapy drug regimen. Any such override 43
process shall be convenient to use by health care providers and an 44
override request shall be expeditiously granted when an insured's 45
treating health care provider demonstrates that the drug regimen 46 Raised Bill No. 5275
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required under step therapy (A) has been ineffective in the past for 47
treatment of the insured's medical condition, (B) is expected to be 48
ineffective based on the known relevant p hysical or mental 49
characteristics of the insured and the known characteristics of the drug 50
regimen, (C) will cause or will likely cause an adverse reaction by or 51
physical harm to the insured, or (D) is not in the best interest of the 52
insured, based on medical necessity. 53
(2) Upon the granting of an override request, the insurance company, 54
hospital service corporation, medical service corporation, health care 55
center or other entity shall authorize dispensation of and coverage for 56
the drug prescribed by the insured's treating health care provider, 57
provided such drug is a covered drug under such policy or contract. 58
(c) Nothing in this section shall (1) preclude an insured or an 59
insured's treating health care provider from requesting a review under 60
sections 38a-591c to 38a-591g, inclusive, or (2) affect the provisions of 61
section 38a-492i. 62
Sec. 2. Section 38a-544 of the general statutes is repealed and the 63
following is substituted in lieu thereof (Effective January 1, 2023): 64
(a) No insurance company, hospital service corporation, medical 65
service corporation, health care center or other entity delivering, issuing 66
for delivery, renewing, amending or continuing a group health 67
insurance policy or contract that provides coverage for prescription 68
drugs may: 69
(1) Require any person covered under such policy or contract to 70
obtain prescription drugs from a mail order pharmacy as a condition of 71
obtaining benefits for such drugs; or 72
(2) Require, if such insurance company, hospital service corporation, 73
medical service corporation, health care center or other entity uses step 74
therapy for such drugs, the use of step therapy for (A) any prescribed 75
drug for longer than sixty days, [or] (B) a prescribed drug for cancer 76
treatment for an insured who has been diagnosed with stage IV 77 Raised Bill No. 5275
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metastatic cancer, provided such prescribed drug is in compliance with 78
approved federal Food and Drug Administration indications, or (C) a 79
prescribed drug for treatment of a mental or behavioral health 80
condition, provided such prescribed drug is in compliance with 81
approved federal Food and Drug Administration indications. 82
(3) At the expiration of the time period specified in subparagraph (A) 83
of subdivision (2) of this subsection or for a prescribed drug described 84
in subparagraph (B) or (C) of subdivision (2) of this subsection, an 85
insured's treating health care provider may deem such step therapy 86
drug regimen clinically ineffective for the insured, at which time the 87
insurance company, hospital service corporation, medical service 88
corporation, health care center or other entity shall authorize 89
dispensation of and coverage for the drug prescribed by the insured's 90
treating health care provider, provided such drug is a covered drug 91
under such policy or contract. If such provider does not deem such step 92
therapy drug regimen clinically ineffective or has not requested an 93
override pursuant to subdivision (1) of subsection (b) of this section, 94
such drug regimen may be continued. For purposes of this section, "step 95
therapy" means a protocol or program that establishes the specific 96
sequence in which prescription drugs for a specified medical condition 97
are to be prescribed. 98
(b) (1) Notwithstanding the sixty-day period set forth in subdivision 99
(2) of subsection (a) of this section, each insurance company, hospital 100
service corporation, medical service corporation, health care center or 101
other entity that uses step therapy for such prescription drugs shall 102
establish and disclose to its health care providers a process by which an 103
insured's treating health care provider may request at any time an 104
override of the use of any step therapy drug regimen. Any such override 105
process shall be convenient to use by health care providers and an 106
override request shall be expeditiously granted when an insured's 107
treating health care provider demonstrates that the drug regimen 108
required under step therapy (A) has been ineffective in the past for 109
treatment of the insured's medical condition, (B) is expected to be 110 Raised Bill No. 5275
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ineffective based on the known relevant physical or mental 111
characteristics of the insured and the known characteristics of the drug 112
regimen, (C) will cause or will likely cause an adverse reaction by or 113
physical harm to the insured, or (D) is not in the best interest of the 114
insured, based on medical necessity. 115
(2) Upon the granting of an override request, the insurance company, 116
hospital service corporation, medical service corporation, health care 117
center or other entity shall authorize dispensation of and coverage for 118
the drug prescribed by the insured's treating health care provider, 119
provided such drug is a covered drug under such policy or contract. 120
(c) Nothing in this section shall (1) preclude an insured or an 121
insured's treating health care provider from requesting a review under 122
sections 38a-591c to 38a-591g, inclusive, or (2) affect the provisions of 123
section 38a-518i. 124
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2023 38a-510
Sec. 2 January 1, 2023 38a-544
PH Joint Favorable