NC H821

Requires health benefit plans and utilization review organizations to base step therapy protocols on clinical practice guidelines developed by independent, multidisciplinary expert panels and grounded in high-quality studies and research.

Establishes five specific conditions for granting step therapy override requests: when the required drug is contraindicated, expected to be ineffective, previously failed, not medically appropriate, or when the patient is stable on their provider's selected drug.

Mandates that patients and prescribing practitioners have access to a clear, convenient, and easily accessible process to request step therapy override determinations through existing medical exceptions processes.

Permits health plans to still require patients to try AB-rated generic equivalents before covering branded drugs and does not restrict providers from prescribing medically appropriate drugs.

Becomes effective January 1, 2016, and applies to health benefit contracts issued, renewed, or amended on or after that date.