SB 1408 — Step therapy protocols; disclosures.

SESSION history | hilite | pdf | print version 17103080D17104550D SENATE BILL NO.

1408 OfferedAMENDMENT JanuaryIN 11,THE 2017NATURE PrefiledOF A SUBSTITUTE (Proposed by the Senate Committee on Commerce and Labor on January 11,23, 20172017) (Patron Prior to Substitute--Senator DeSteph) A BILL to amend the Code of Virginia by adding a section numbered 38.2-3407.9:04, relating to accident and sickness insurance;

----------Be Patrons--it DeSteph,enacted Lewisby andthe Spruill;General Assembly of Virginia:

Delegates:

Knight and Rasoul ---------- Referred to Committee on Commerce and Labor ---------- Be it enacted by the General Assembly of Virginia:

"Carrier" includes any entity administering a policy or plan providing health coverage to state employees pursuant to § 2.2-2818.

"Health benefit plan" includes any policy or plan providing health coverage to state employees pursuant to § 2.2-2818.

"Step therapy protocol" means a protocol or program that (i) establishes the specific sequence in which prescription drugs for a specified medical condition are medically appropriate for a particular patient and are covered byunder a healthpharmacy or medical benefit planby a carrier, including self-administered and physician-administered drugs, or (ii) in any way conditions coverage of a prescription medication on a patient first trying an alternative medication without success.

or 4.

A medical opinion is given by a second provider, not affiliated with the prescribing provider, reconfirming that the prescribed therapy is in the best interest of the patient based upon their personal examination of the patient and medical test results.results;

5.

The required prescription drug is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug regimen;

or 6.

Based on clinical appropriateness, a preceding prescription drug is not in the best interest of the covered individual because the covered individual's use of the preceding prescription drug is expected to:

a.

Be a significant barrier to the covered individual's adherence to or compliance with the covered individual's plan of care;

b.

Worsen a comorbid condition of the covered individual;

or c.

Decrease the covered individual's ability to achieve or maintain reasonable functional ability in performing daily activities.

A patient shall not be prohibited from paying, with his own resources and not through benefits of a health benefit plan, for a prescribed therapy, in lieu of a therapy that would be covered under the step therapy protocol, during the period preceding the date that the prescribed therapy would be covered under the health benefit plan pursuant to the step therapy protocol.

Upon the expiration of such period, the prescribed therapy shall be covered under the health benefit plan to the same extent that it would be covered if the patient had received other therapy during such period pursuant to the step therapy protocol.

F.

F.

The carrier or utilization review organization shall respond to a step therapy override exception request or an appeal within 72 hours of receipt;

however, in cases where exigent circumstances exist a carrier or utilization review organization shall respond within 24 hours of receipt.

If the carrier or utilization review organization does not respond within the applicable period following receipt, the exception or appeal shall be deemed granted.