HB 216 Summary

• Establishes minimum standards for step therapy protocols used by health insurers and utilization review organizations requiring patients to try specific prescription drugs in a particular sequence before coverage approval.

• Requires clinical review criteria for step therapy protocols to be based on clinical practice guidelines developed by multidisciplinary expert panels with transparent processes, conflict-of-interest management, and continuous updates based on new evidence.

• Creates a process for patients and prescribers to request step therapy exceptions through a clear, accessible mechanism with determinations made within 72 hours (or 24 hours in exigent circumstances); deemed approved if no determination made within timeframe.

• Grants step therapy exceptions when a patient is currently stabilized on a drug or when required step therapy drugs are contraindicated, expected to be ineffective, previously failed, or not in the patient's best interest based on medical necessity.

• Requires insurers and utilization review organizations to annually certify compliance with standards to the insurance commissioner and submit reports on exception requests, approval rates, denial reasons, and medical conditions qualifying for exceptions.