2016 -- S 2694

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2016

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A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES -

STEP THERAPY PROTOCOL

     

     Introduced By: Senators Gallo, and Lynch Prata

     Date Introduced: March 08, 2016

     Referred To: Senate Health & Human Services

     It is enacted by the General Assembly as follows:

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     SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness

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Insurance Policies" is hereby amended by adding thereto the following sections:

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     27-18-82. Definitions. -- (a) As used in this chapter:

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     (1) "Clinical practice guidelines" means a systematically developed statement to assist

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decision making by health care providers and patients about appropriate health care for specific

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clinical circumstances and conditions.

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     (2) "Clinical review criteria" means the written screening procedures, decision abstracts,

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clinical protocols and practice guidelines used by an insurer, health plan, or utilization review

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organization to determine the medical necessity and appropriateness of health care services.

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     (3) "Medically necessary" means health services and supplies that under the applicable

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standard of care are appropriate:

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     (i) To improve or preserve health, life, or function; or

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     (ii) To slow the deterioration of health, life, or function; or

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     (iii) For the early screening, prevention, evaluation, diagnosis, or treatment of a disease,

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condition, illness, or injury.

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     (4) "Step therapy override exception determination" means a determination as to whether

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a step therapy protocol should apply in a particular situation, or whether the step therapy protocol

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should be overridden in favor of immediate coverage of the health care provider's selected

 

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prescription drug. This determination is based on a review of the patient's or prescriber's request

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for an override, along with supporting rationale and documentation.

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     (5) "Step therapy protocol" means a protocol or program that establishes the specific

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sequence in which prescription drugs for a specified medical condition and medically appropriate

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for a particular patient are covered by an insurer or health plan.

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     (6) "Utilization review organization" means an entity that conducts a utilization review,

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other than an insurer or health plan performing utilization reviews for its own health benefit

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plans.

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     27-18-83. Exceptions process transparency. -- (a) Exceptions process. When coverage

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of a prescription drug for the treatment of any medical condition is restricted for use by an

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insurer, health plan, or utilization review organization through the use of a step therapy protocol,

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the patient and prescribing practitioner shall have access to a clear, readily accessible and

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convenient process to request a step therapy exception determination. An insurer, health plan, or

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utilization review organization may use its existing medical exceptions process to satisfy this

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requirement. The process shall be made easily accessible on the insurers, health plans, or

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utilization review organization's website.

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     (b) Exceptions. A step therapy override exception determination request shall be

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expeditiously granted if:

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     (1) The required prescription drug is contraindicated, or will likely cause an adverse

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reaction or physical or mental harm to the patient;

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     (2) The required prescription drug is expected to be ineffective based on the known

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clinical characteristics of the patient, and the known characteristics of the prescription drug

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regimen;

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     (3) The patient has tried the required prescription drug while under their current or a

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previous health insurance or health benefit plan, or another prescription drug in the same

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pharmacologic class, or with the same mechanism of action and such prescription drug was

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discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event;

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     (4) The required prescription drug is not in the best interest of the patient based on

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medical necessity;

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     (5) The patient is stable on a prescription drug selected by their health care provider for

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the medical condition under consideration;

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     (6) The required prescription drug is likely to be diverted.

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     (c) Effect of exception. Upon the granting of a step therapy override exception

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determination, the insurer, health plan, or utilization review organization shall authorize coverage

 

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for the prescription drug prescribed by the patient's treating health care provider.

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     (d) Limitations. This section shall not be construed to prevent:

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     (1) An insurer, health plan, or utilization review organization from requiring a patient to

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try an AB-rated generic equivalent prior to providing coverage for the equivalent branded

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prescription drug;

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     (2) A health care provider from prescribing a prescription drug that is determined to be

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medically appropriate.

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     27-18-84. Regulations. – Notwithstanding any provision of the general or public laws to

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the contrary, the office of the health insurance commissioner shall promulgate any regulations

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necessary to enforce the provisions of §§27-18-82 and 27-18-83 in accordance with the

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provisions of chapter 35 of title 42 ("administrative procedures act").

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     SECTION 2. This act shall take effect upon passage and shall apply only to health

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insurance and health benefit plans delivered, issued for delivery, or renewed on or after June 1,

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2016.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES -

STEP THERAPY PROTOCOL

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     This act would allow for a step therapy exception determination when coverage of a

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prescription drug for the treatment of a medical condition is restricted for use by an insurer,

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health plan, or utilization review organization.

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     This act shall take effect upon passage and shall apply only to health insurance and health

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benefit plans delivered, issued for delivery, or renewed on or after June 1, 2016.

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