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General Assembly Substitute Bill No. 182
February Session, 2024
AN ACT PROHIBITING CERTAIN HEALTH CARRIERS FROM
REQUIRING STEP THERAPY FOR PRESCRIPTION DRUGS USED TO
TREAT A MENTAL OR BEHAVIORAL HEALTH CONDITION OR A
CHRONIC, DISABLING OR LIFE-THREATENING CONDITION.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Section 38a-510 of the 2024 supplement to the general 1
statutes is repealed and the following is substituted in lieu thereof 2
(Effective January 1, 2025): 3
(a) No insurance company, hospital service corporation, medical 4
service corporation, health care center or other entity delivering, issuing 5
for delivery, renewing, amending or continuing an individual health 6
insurance policy or contract that provides coverage for prescription 7
drugs may: 8
(1) Require any person covered under such policy or contract to 9
obtain prescription drugs from a mail order pharmacy as a condition of 10
obtaining benefits for such drugs; or 11
(2) Require, if such insurance company, hospital service corporation, 12
medical service corporation, health care center or other entity uses step 13
therapy for such drugs, the use of step therapy (A) for any prescribed 14
drug for longer than [thirty] twenty days, (B) for a prescribed drug for 15 Substitute Bill No. 182
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cancer treatment for an insured who has been diagnosed with stage IV 16
metastatic cancer provided such prescribed drug is in compliance with 17
approved federal Food and Drug Administration indications, [or] (C) 18
for the period commencing January 1, 2024, and ending January 1, 2027, 19
inclusive, for the treatment of schizophrenia, major depressive disorder 20
or bipolar disorder, as defined in the most recent edition of the 21
American Psychiatric Association's "Diagnostic and Statistical Manual 22
of Mental Disorders", (D) for the period commencing January 1, 2025, 23
for a prescribed drug for the treatment of a mental or behavioral health 24
condition, provided such prescribed drug is in compliance with 25
approved federal Food and Drug Administration indications, or (E) for 26
the period commencing January 1, 2025, for a prescribed drug for the 27
treatment of a chronic, disabling or life-threatening condition or disease, 28
provided such prescribed drug is in compliance with approved federal 29
Food and Drug Administration indications. 30
(3) At the expiration of the time period specified in subparagraph (A) 31
of subdivision (2) of this subsection or for a prescribed drug described 32
in subparagraph (B), [or] (C), (D) or (E) of subdivision (2) of this 33
subsection, an insured's treating health care provider may deem such 34
step therapy drug regimen clinically ineffective for the insured, at which 35
time the insurance company, hospital service corporation, medical 36
service corporation, health care center or other entity shall authorize 37
dispensation of and coverage for the drug prescribed by the insured's 38
treating health care provider, provided such drug is a covered drug 39
under such policy or contract. If such provider does not deem such step 40
therapy drug regimen clinically ineffective or has not requested an 41
override pursuant to subdivision (1) of subsection (b) of this section, 42
such drug regimen may be continued. For purposes of this section, "step 43
therapy" means a protocol or program that establishes the specific 44
sequence in which prescription drugs for a specified medical condition 45
are to be prescribed. 46
(b) (1) Notwithstanding the [sixty-day] twenty-day period set forth 47
in subparagraph (A) of subdivision (2) of subsection (a) of this section, 48 Substitute Bill No. 182
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each insurance company, hospital service corporation, medical service 49
corporation, health care center or other entity that uses step therapy for 50
such prescription drugs shall establish and disclose to its health care 51
providers a process by which an insured's treating health care provider 52
may request at any time an override of the use of any step therapy drug 53
regimen. Any such override process shall be convenient to use by health 54
care providers and an override request shall be expeditiously granted 55
when an insured's treating health care provider demonstrates that the 56
drug regimen required under step therapy (A) has been ineffective in 57
the past for treatment of the insured's medical condition, (B) is expected 58
to be ineffective based on the known relevant physical or mental 59
characteristics of the insured and the known characteristics of the drug 60
regimen, (C) will cause or will likely cause an adverse reaction by or 61
physical harm to the insured, or (D) is not in the best interest of the 62
insured, based on medical necessity. 63
(2) Upon the granting of an override request, the insurance company, 64
hospital service corporation, medical service corporation, health care 65
center or other entity shall authorize dispensation of and coverage for 66
the drug prescribed by the insured's treating health care provider, 67
provided such drug is a covered drug under such policy or contract. 68
(c) Nothing in this section shall (1) preclude an insured or an 69
insured's treating health care provider from requesting a review under 70
sections 38a-591c to 38a-591g, inclusive, or (2) affect the provisions of 71
section 38a-492i. 72
Sec. 2. Section 38a-544 of the 2024 supplement to the general statutes 73
is repealed and the following is substituted in lieu thereof (Effective 74
January 1, 2025): 75
(a) No insurance company, hospital service corporation, medical 76
service corporation, health care center or other entity delivering, issuing 77
for delivery, renewing, amending or continuing a group health 78
insurance policy or contract that provides coverage for prescription 79
drugs may: 80 Substitute Bill No. 182
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(1) Require any person covered under such policy or contract to 81
obtain prescription drugs from a mail order pharmacy as a condition of 82
obtaining benefits for such drugs; or 83
(2) Require, if such insurance company, hospital service corporation, 84
medical service corporation, health care center or other entity uses step 85
therapy for such drugs, the use of step therapy (A) for any prescribed 86
drug for longer than [thirty] twenty days, (B) for a prescribed drug for 87
cancer treatment for an insured who has been diagnosed with stage IV 88
metastatic cancer provided such prescribed drug is in compliance with 89
approved federal Food and Drug Administration indications, [or] (C) 90
for the period commencing January 1, 2024, and ending January 1, 2027, 91
inclusive, for the treatment of schizophrenia, major depressive disorder 92
or bipolar disorder, as defined in the most recent edition of the 93
American Psychiatric Association's "Diagnostic and Statistical Manual 94
of Mental Disorders", (D) for the period commencing January 1, 2025, 95
for a prescribed drug for the treatment of a mental or behavioral health 96
condition, provided such prescribed drug is in compliance with 97
approved federal Food and Drug Administration indications, or (E) for 98
the period commencing January 1, 2025, for a prescribed drug for the 99
treatment of a chronic, disabling or life-threatening condition or disease, 100
provided such prescribed drug is in compliance with approved federal 101
Food and Drug Administration indications. 102
(3) At the expiration of the time period specified in subparagraph (A) 103
of subdivision (2) of this subsection or for a prescribed drug described 104
in subparagraph (B), [or] (C), (D) or (E) of subdivision (2) of this 105
subsection, an insured's treating health care provider may deem such 106
step therapy drug regimen clinically ineffective for the insured, at which 107
time the insurance company, hospital service corporation, medical 108
service corporation, health care center or other entity shall authorize 109
dispensation of and coverage for the drug prescribed by the insured's 110
treating health care provider, provided such drug is a covered drug 111
under such policy or contract. If such provider does not deem such step 112
therapy drug regimen clinically ineffective or has not requested an 113 Substitute Bill No. 182
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override pursuant to subdivision (1) of subsection (b) of this section, 114
such drug regimen may be continued. For purposes of this section, "step 115
therapy" means a protocol or program that establishes the specific 116
sequence in which prescription drugs for a specified medical condition 117
are to be prescribed. 118
(b) (1) Notwithstanding the [sixty-day] twenty-day period set forth 119
in subparagraph (A) of subdivision (2) of subsection (a) of this section, 120
each insurance company, hospital service corporation, medical service 121
corporation, health care center or other entity that uses step therapy for 122
such prescription drugs shall establish and disclose to its health care 123
providers a process by which an insured's treating health care provider 124
may request at any time an override of the use of any step therapy drug 125
regimen. Any such override process shall be convenient to use by health 126
care providers and an override request shall be expeditiously granted 127
when an insured's treating health care provider demonstrates that the 128
drug regimen required under step therapy (A) has been ineffective in 129
the past for treatment of the insured's medical condition, (B) is expected 130
to be ineffective based on the known relevant physical or mental 131
characteristics of the insured and the known characteristics of the drug 132
regimen, (C) will cause or will likely cause an adverse reaction by or 133
physical harm to the insured, or (D) is not in the best interest of the 134
insured, based on medical necessity. 135
(2) Upon the granting of an override request, the insurance company, 136
hospital service corporation, medical service corporation, health care 137
center or other entity shall authorize dispensation of and coverage for 138
the drug prescribed by the insured's treating health care provider, 139
provided such drug is a covered drug under such policy or contract. 140
(c) Nothing in this section shall (1) preclude an insured or an 141
insured's treating health care provider from requesting a review under 142
sections 38a-591c to 38a-591g, inclusive, or (2) affect the provisions of 143
section 38a-518i. 144 Substitute Bill No. 182
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This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2025 38a-510
Sec. 2 January 1, 2025 38a-544
PH Joint Favorable Subst.