NY S08191

Step therapy protocols cannot require prescription drugs not approved by the FDA for the medical condition being treated.

Step therapy protocols cannot require an insured to try and fail on more than one drug before providing coverage for the prescribed drug.

Step therapy protocols cannot require use of a required drug for longer than 30 days, cannot be imposed if the insured took the prescribed drug within the past 365 days, and cannot require newly enrolled patients to repeat step therapy already completed under a prior plan.

Health care professional attestations that a required drug has failed must be accepted as prima facie evidence of failure.

Step therapy protocol override approvals must be honored until the later of 12 months following approval or plan renewal, and utilization review agents' failure to comply with these requirements is grounds for granting a protocol override.