Raised Bill No. 415 Summary

• Prohibits health carriers from requiring step therapy for drugs treating behavioral health conditions or chronic, disabling, or life-threatening conditions for longer than 60 days, effective January 1, 2023.

• Redefines "clinical peer" to require board certification in relevant specialties and active practice in the field being reviewed, with specific requirements for substance use disorder and mental health reviews.

• Shifts burden of proof to health carriers, requiring them to demonstrate that health care services are not medically necessary rather than placing burden on patients to prove medical necessity.

• Grants clinical peers authority to reverse initial adverse determinations after conferencing with treating health care providers, provided no formal grievance has been filed.

• Applies to both individual and group health insurance policies covering prescription drugs, and establishes specific clinical review criteria requirements for substance use disorder and mental health treatment.