Bill > H791

This bill establishes new requirements and restrictions for prescription drug coverage, particularly concerning "step therapy protocols," which are programs that dictate the order in which certain medications for a specific condition must be tried before a health plan will cover a different, potentially preferred, drug. The bill mandates that the criteria used for these protocols must be based on "clinical practice guidelines" developed by relevant medical societies. Crucially, it creates a clear and accessible process for patients and their doctors to request an exception, or a "Step Therapy Override Determination," to the protocol. Such exceptions must be granted if the prescribed drug is contraindicated, likely to be ineffective, if the patient has already tried and failed the required drug, if the patient is stable on their current medication, or if the required drug is not in the patient's best interest. The bill applies these provisions to various types of health insurance plans, including those regulated under Chapters 175, 176A, 176B, and 176G of the General Laws, and specifies that these changes will take effect for policies renewed on or after January 1, 2016.