NY S03419

Establishes expedited procedures for step therapy protocol overrides within 72 hours (or 24 hours for serious medical jeopardy) when a health care professional provides supporting clinical documentation meeting specified criteria.

Requires utilization review agents to use evidence-based and peer-reviewed clinical review criteria that account for atypical patient populations when establishing or reviewing step therapy protocols.

Grants step therapy override determinations when prescription drugs are contraindicated, expected to be ineffective, previously unsuccessful, patient is stable on alternative medication, or the required drug would impair treatment adherence or worsen comorbid conditions.

Requires clinical review criteria relating to step therapy overrides be made available to health care professionals upon written request, in addition to current requirements for insureds.

Deems failure to meet step therapy override timeframes as an automatic override of the step therapy protocol rather than a standard adverse determination.

Takes effect January 1, 2017, for health insurance and health benefit plans delivered or renewed after that date.