IL SB3037

Expands medical exceptions process to all Illinois insurers and health plans selling group or individual accident and health insurance, not just those offering qualified health plans under the Affordable Care Act.

Requires insurers to establish procedures allowing covered persons to request coverage of clinically appropriate prescription drugs when drugs are not on formulary, being discontinued, step therapy alternatives have failed or are contraindicated, or dose restrictions are ineffective.

Mandates insurers approve or deny coverage requests within 72 hours (or 24 hours for expedited determinations) and provide reasons for denials, alternative medications, and appeal procedures.

Requires step therapy override requests be expeditiously granted in five specific circumstances: drug is contraindicated, likely ineffective based on patient characteristics, patient previously failed same or similar drug, drug is not in patient's best medical interest, or patient is stable on current prescribed drug.

Requires clinical review criteria for step therapy protocols be based on independent, multidisciplinary clinical practice guidelines developed through transparent processes using high-quality evidence, with continuous updates as new research emerges.

Ensures prescription drugs approved through step therapy exceptions are available at the preferred cost-sharing level once clinical prerequisites are satisfied, while preserving tiered copayment structures.