The bill requires the department of health care policy and
financing (state department) to grant an exception to step therapy if the prescribing provider submits a prior authorization request with justification and supporting clinical documentation for treatment of a serious or complex medical condition. The bill requires the state department to provide a response to a prior authorization request for a step-therapy exception within 24 hours after receipt of the request.
If a prior authorization request for a step-therapy exception is
incomplete or if additional clinically relevant information is required, the bill requires the state department to notify the prescribing provider within 24 hours after the submission of the request. If the state department does not receive a response within 72 hours after the state department's request for additional information, the prior authorization is denied. If the prior authorization request is denied, the bill requires the state department to inform the recipient in writing that the recipient has a right to appeal the determination.
If the state department does not make a determination regarding
the step-therapy exception request, respond to the appeal of the denial of the request, or request additional clinically relevant information, the step-therapy exception request or the appeal of the denial is deemed granted. The bill requires the state department to authorize coverage for the prescription drug prescribed by the recipient's prescribing provider if the prior authorization request for a step-therapy exception request is granted.
The bill requires the state department to make the prior
authorization requirements for coverage of prescription drugs and a description of the step-therapy exemption process available on the state department's website and provide to the recipient, upon written request, all specific clinical review criteria and other clinical information relating to a recipient's particular condition or disease.
