Step therapy protocols; disclosures.

Requires health benefit plans that restrict the use of any prescription drug through the use of a step therapy protocol to have in place a clear, convenient, and expeditious process for a prescribing medical provider to request an override of such restrictions for a patient. A step therapy protocol is a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition are medically appropriate for a particular covered person and are covered by a health benefit plan or that conditions coverage of a prescription medication on a patient first trying an alternative medication without success. The measure requires the granting of a step therapy protocol override if (i) the required prescription drug is contraindicated or will likely cause an adverse reaction or physical or mental harm to the patient; (ii) the required prescription drug is expected to be ineffective on the basis of the known relevant physical or mental characteristics of the covered person and the known characteristics of the prescription drug regimen; (iii) the covered person has tried the required prescription drug while under his current or a previous health benefit plan or another prescription drug in the same pharmacologic class or with the same mechanism of action and such prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event; or (iv) the required prescription drug is not in the best interest of the covered person, based on medical appropriateness.