RI H7539

Insurers must grant step therapy exceptions when required treatments are contraindicated, previously ineffective, likely ineffective based on clinical history, would delay medically necessary care, or would disrupt current stable treatment

Exception requests must be decided within 72 hours (24 hours for urgent cases), with requests automatically granted if no determination is made within these timeframes

Step therapy protocols cannot require patients to fail more than one prescription drug before coverage is authorized, and patients cannot be required to remain on a required step longer than 30 calendar days

Step therapy protocols are prohibited for treatments for serious mental illness, cancer (including metastatic and hematologic), and rare diseases with limited treatment options

Insurers must provide the Office of the Health Insurance Commissioner with utilization and outcome data to evaluate whether step therapy protocols delay or deny medically necessary care, and the Commissioner has enforcement authority including power to impose fines for noncompliance