Health Insurance:
Step Therapy

This chart highlights the state laws related to step therapy for prescription drug coverage.

If you have a self-funded plan, certain state laws may not apply. For information on how to determine if your plan is self-funded, see our blog post.

For more health insurance information, visit our Health Insurance Materials & Resources.

StateState Law That Protects Consumers Related to Step TherapyDescription of the State Law Related to Step TherapyState Law That Protects Consumers with a Specific Health Condition, Related to Step TherapyOther State Law Related to Step Therapy
ALABAMA
ALASKA
ARIZONAArizona Revised Statutes Title 20 - Insurance, Chapter 31 - Step Therapy, §§ 20-3651 to 3654https://www.azleg.gov/viewdocument/?docName=https://www.azleg.gov/ars/20/03651.htmStep therapy protocols must be developed either by a multidisciplinary panel of experts based on research and medical practice, or in accordance with peer-reviewed publications. Health plans must establish and publish a clear and accessible process for requesting an exception. An exception must be granted if the drug required by the protocol is contraindicated or is likely to cause a serious adverse reaction; if the drug is expected to be ineffective based on the known characteristics of the patient and the drug; if the patient has previously tried the drug or a similar one; if the drug is not in the best interest of the patient; or if the patient is experiencing a positive therapeutic outcome on their current prescribed drug. Exceptions must be granted within 72 hours of the request, or within 24 hours if exigent circumstances exist.
ARKANSASArkansas Code Title 23 - Public Utilities and Regulated Industries, Subtitle 3 - Insurance, Chapter 70 - Insurance Policies, Subchapter 21 - Regulation of Step Therapy Protocols Generally, §§ 23-79-2101 to 2105https://advance.lexis.com/documentpage/?pdmfid=1000516&crid=f1ddbac9-4c6f-4cb7-9315-da9fb44f3f82&nodeid=AAXAADAAVAAWAAC&nodepath=%2FROOT%2FAAX%2FAAXAAD%2FAAXAADAAV%2FAAXAADAAVAAW%2FAAXAADAAVAAWAAC&level=5&haschildren=&populated=false&title=23-79-2101.+Legislative+findings+and+intent.&config=00JAA2ZjZiM2VhNS0wNTVlLTQ3NzUtYjQzYy0yYWZmODJiODRmMDYKAFBvZENhdGFsb2fXiYCnsel0plIgqpYkw9PK&pddocfullpath=%2Fshared%2Fdocument%2Fstatutes-legislation%2Furn%3AcontentItem%3A623Y-B850-R03P-02SN-00008-00&ecomp=6gf5kkk&prid=1a977ce6-f25f-4373-a861-0dbdedd81339Step therapy protocols must be established using clinical practice guidelines or in accordance with peer-reviewed publications. The insurer must provide a clear, readily accessible, and convenient process to request an exception. An exception must be granted if the protocol-required drug is contraindicated or will likely cause a serious adverse reaction; if the drug is expected to be ineffective based on the known characteristics of the patient and the drug; if the patient has previously tried the drug or a similar drug and it was discontinued due to lack of or diminished efficacy or an adverse event; if the drug is not in the best interest of the patient; or if the patient is stable on their current prescribed drug. Exceptions be decided within 72 hours or within 24 hours if exigent circumstances exist.Arkansas Code Title 23 - Public Utilities and Regulated Industries, Subtitle 3 - Insurance, Chapter 99 - Healthcare Providers, Subchapter 11 - Prior Authorization Transparency Act, §§ 23-99-1114 - Limitation on Step Therapy - Definitions (prohibits use of step therapy for Metastatic cancer unless certain conditions are met; also prohibits step therapy for treatment of psychosis and serious mental illness with antipsychotic prescription drugs)https://advance.lexis.com/documentpage/?pdmfid=1000516&crid=1b0be515-1f59-4cd3-a109-9b233cc8db8d&nodeid=AAXAADABPAAMAAP&nodepath=%2FROOT%2FAAX%2FAAXAAD%2FAAXAADABP%2FAAXAADABPAAM%2FAAXAADABPAAMAAP&level=5&haschildren=&populated=false&title=23-99-1114.+Limitation+on+step+therapy+%E2%80%94+Definitions.&config=00JAA2ZjZiM2VhNS0wNTVlLTQ3NzUtYjQzYy0yYWZmODJiODRmMDYKAFBvZENhdGFsb2fXiYCnsel0plIgqpYkw9PK&pddocfullpath=%2Fshared%2Fdocument%2Fstatutes-legislation%2Furn%3AcontentItem%3A68H3-DM90-R03K-V40S-00008-00&ecomp=6gf5kkk&prid=6b2a2462-5d05-45d8-8f7a-7da4cc01819aAct 513 of th Arkansas Legislature 2025 Regular Section - Amends Arkansas Code Title 23, Chapter 79 to Add Subchapter 29 - Coverage for Noninvasive Ventilators (prohibits use of step therapy for non-invasive ventilators if certain conditions are met)https://www.arkleg.state.ar.us/Home/FTPDocument?path=%2FACTS%2F2025R%2FPublic%2FACT513.pdf
CALIFORNIACalifornia Health and Safety Code, Division 2 - Licensing Provisions, Chapter 22, §§ 1367.206, 1367.241, and 1367.244https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=HSC&division=2.&title=&part=&chapter=2.2.&article=5.Step therapy may only be used in accordance with clinical practice guidelines. Exceptions to step therapy must be granted if the required prescription drug is contraindicated; would likely cause an adverse reaction or other harm; is expected to be ineffective; prior attempts to use the same or a pharmacologically similar drug were discontinued due to ineffectiveness, diminished effect, or an adverse event; the required drug is not clinically appropriate; or the patient is currently stable on the prescribed drug. Insurers are required to review requests for step therapy exceptions and must approve such requests within seventy-two hours for nonurgent cases and within twenty-four hours in exigent circumstances.
COLORADOColorado Revised Statutes Title 10 - Insurance, Article 16 - Health-care Coverage, § 10-16-145 – Step Therapyhttps://colorado.public.law/statutes/crs_10-16-145tep therapy may only be used in accordance with clinical practice guidelines. Information about clinical review criteria and how to request a step therapy exemption must be available online or provided upon written request. Exceptions to step therapy must be granted if the required prescription drug is contraindicated; would likely cause an adverse reaction or other harm; is ineffective; prior attempts to use the same or a pharmacologically similar drug were discontinued because it was ineffective, had a diminished effect, or caused an adverse event; or if someone has previously gone through step therapy and is currently stable on the prescription drug. Exception requests must be decided—or additional information needed to make a decision must be requested—within three business days, or within 24 hours if exigent circumstances exist. If no decision is made within the required timeframe, the request is deemed granted.Colorado Revised Statutes Title 10 - Insurance, Article 16 - Health-care Coverage, § 10-16-145 (prohibits use of step therapy for patients with stage four advanced metastatic cancer if certain conditions are met)https://colorado.public.law/statutes/crs_10-16-145.5
CONNECTICUTConnecticut General Statutes Cnapter 700 c Health Insurance, § 38a-510 and § 38a-544 – Prescription Drug Coverage. Mail order pharmacies. Step therapy Use.https://www.cga.ct.gov/current/pub/chap_700c.htm#sec_38a-510Prohibits insurers from requiring step therapy for any drug for longer than 30 days. Prohibits insurers from requiring step therapy for any stage IV metastatic cancer prescription drug if certain conditions are met. Prohibits the use of step therapy drugs for schizophrenia, major depressive disorder, or bipolar disorder. Allows providers to deem a step therapy drug regimen clinically ineffective; also provides for an override process if step therapy has been ineffective in the past, is expected to be ineffective based on information known about the patient and the drug, will cause or is likely to cause an adverse reaction or physical harm, or is not in the patient's best interest.
DELAWAREDelaware Code Title 18, Chapter 33, Subchapter II – Pre-Authorization Transparency, § 3381 Step therapy exception processhttps://delcode.delaware.gov/title18/c033/sc02/index.htmlRequires insurers to have and publish a clear and convenient process to request step therapy exception determinations. Step therapy exceptions must be granted if the required drug is contraindicated or will likely cause harm to the patient; the patient has tried the required drug or a drug in the same class under their current or previous health plan; the drug is not in the medically necessary best interest of the patient; or the patient is stable on the prescription drug selected by their provider. Requires step therapy exception determinations within two business days for non-urgent requests and within twenty-four hours for urgent requests.
*DISTRICT OF COLUMBIAD.C. Law 22-242 Behavioral Health Parity Act of 2018https://code.dccouncil.gov/us/dc/council/laws/22-242Prohibits use of step therapy for medication-assisted treatment of substance use disorders.
FLORIDAFlorida Statutes Title XXXVII - Insurance, Chapter 627 - Insurance Rates and Contracts, § 627.42393 – Step Therapyhttp://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0600-0699/0627/Sections/0627.42393.htmlProhibits insurers from requiring patients to follow a step therapy protocol for a prescription drug when the patient has completed a step therapy protocol for that same drug as required by a separate insurer, and that separate insurer has paid for the drug during the ninety days prior to the current request. Requires insurers to publish the process for requesting a protocol exemption and appealing denials, and provides minimum standards for what the process must include.
GEORGIAGeorgia Code Title 33 - Insurance, Chapter 24 - Insurance Generally, Article 1 - General Provisions, § 33-24-59.25 - Establishment by health benefit plans of step therapy protocols; exception process; time requirements; appeals; construction; application.https://advance.lexis.com/documentpage/?pdmfid=1000516&crid=b19775db-a5a9-4991-bb5d-29f4aab2f783&config=00JAA1MDBlYzczZi1lYjFlLTQxMTgtYWE3OS02YTgyOGM2NWJlMDYKAFBvZENhdGFsb2feed0oM9qoQOMCSJFX5qkd&pddocfullpath=%2Fshared%2Fdocument%2Fstatutes-legislation%2Furn%3AcontentItem%3A6348-FXD1-DYB7-W169-00008-00&pdcontentcomponentid=234186&pdteaserkey=sr1&pditab=allpods&ecomp=6s65kkk&earg=sr1&prid=68edc193-0fe8-4ae0-a1b5-089e4a281ca5Step therapy exceptions must be granted if the required drug is contraindicated or will likely cause an adverse reaction or harm to the patient; is expected to be ineffective based on the known condition of the patient and the characteristics of the drug; has been previously tried by the patient—or is in the same class as a drug previously tried under their current or previous health plan—and was discontinued due to lack of efficacy, diminished effect, or an adverse event; is not in the medically necessary best interest of the patient; or if the patient is stable on the prescription drug selected by their provider and the provider submits documentation indicating that the step therapy-required drug is expected to be ineffective or cause harm. Step therapy exception determinations must be made within two business days for non-urgent requests and within 24 hours for urgent requests.
HAWAIIStudy of Proposed Mandatory Health Insurance Coverage Regarding Step Therapy Requirements for Stage 2 Through Stage 5 Cancer
IDAHO
ILLINOISThe Managed Care Reform and Patient Rights Act (will amend 215 ILCS 134/87; all provisions go into effect January 1, 2026)https://www.ilga.gov/Legislation/ILCS/Articles?ActID=1265&ChapterID=22Effective January 1, 2026, Illinois has banned the use of step-therapy.Step therapy is prohibited beginning on January 1, 2026; however, this prohibition does not apply to health care plans operated or overseen by the Department of Healthcare and Family Services, including Medicaid managed care plans, for drugs that do not appear on the most recent Preferred Drug List published by the Department of Healthcare and Family Services.
INDIANAIndiana Code Title 27 - Insurance, Article 13 - Health Maintenance Organizations, Chapter 7- Requirements for Group Contracts, Individual Contracts, and Evidence of Coverage, 23 Step Therapy Protocol, § 27-13-7-23https://iga.in.gov/laws/2018/ic/titles/27#27-13-7-23The insurer must publish a procedure to request a step therapy protocol exception. The insurer must grant a step therapy exception request if the required drug is contraindicated or will likely cause an adverse reaction or harm to the patient; the required drug is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the drug; the patient has previously received the drug, a drug in the same pharmacologic class, or a drug with the same mechanism of action, and the drug was discontinued due to inefficacy or an adverse event; or the required drug is not in the best interest of the patient because it is expected to create a significant barrier to care, worsen a comorbid condition, or decrease the patient’s ability to maintain reasonable function in daily activities. A determination on the exception request must be made within three business days for non-urgent requests and within one business day for urgent requests. IC 27-8-5-30 applies these same provisions to those covered under a policy of accident and sickness insurance.Indiana Code Title 5 - State and Local Administration, Article 10 - Public Employee Benefits, Chapter 8 - Group Insurance for Public Employees, § IC 5-10-8-17 (applies to those covered under a state employee health plan)https://iga.in.gov/laws/2018/ic/titles/5#5-10-8-17
IOWAIowa Administrative Code Chapter 514F.7 - Use of Step Therapy Protocolshttps://www.legis.iowa.gov/docs/code/514F.7.pdfThe insurer must grant a step therapy exception request if the required drug is contraindicated or is likely to cause an adverse reaction, decrease functional ability, or cause harm to the patient; if the required drug is expected to be ineffective based on the known clinical characteristics of the patient and the drug; if the patient has previously received the drug and it was discontinued due to ineffectiveness; or if the patient is receiving a positive outcome from a drug selected by their provider. Exception request determinations are required within five calendar days for non-urgent requests and within seventy-two hours for urgent requests.
KANSASKansas Statutes Chapter 39, Article 7 - Social Welfare, Section 121, §39-7,121 - Electronic pharmacy claims management system; limitations on utilization of system; implementation of system; reporting requirements.https://www.kslegislature.gov/li_2016/b2015_16/statute/039_000_0000_chapter/039_007_0000_article/039_007_0121_section/039_007_0121_k/Requires the Department of Health and Environment, which oversees Kansas's Medicaid programs, to allow physicians to request an override of any requirement that a patient use and fail a drug if: the drug is contraindicated or likely to cause an adverse reaction or harm; the drug is expected to be ineffective based on clinical characteristics of the patient and drug; the patient has tried the drug but use was discontinued due to lack of efficacy, diminished effect, or an adverse event; or the patient is stable on a drug selected by the physician. The insurer shall decide an exception request within 72 hours.
KENTUCKYKentucky Revised Statutes Title XXV Business and Financial Institutions, Chapter 304 Insurance Code, Subtitle 17A Health Benefit Plans, § 163 - Establishment of clinical review criteria - Override of restrictions on medication sequence in step therapyhttps://apps.legislature.ky.gov/law/statutes/statute.aspx?id=54758Requires the use of clinical review criteria or peer-reviewed publications to develop step therapy protocols. Requires the use of a clear, readily accessible, and convenient process to request a step therapy exception if the drug is contraindicated, likely to cause an adverse reaction or physical harm; is expected to be ineffective based on the clinical characteristics of the insured and the prescription drug regimen; or is not in the patient's best interest because the drug is expected to cause a significant barrier to adherence to or compliance with the plan of care, worsen a comorbid condition, or decrease functioning. An exception must also be granted if the patient has tried the same or a similar drug before, but it was discontinued due to lack of efficacy, diminished effect, or an adverse event; or if the patient is stable on the drug selected by their provider. Exception requests must be decided within 48 hours.
LOUISIANALouisiana Revised Statutes Title 22, § 22:1053 - Requirement for coverage of step therapy or fail first protocols; prohibitions; definitionshttps://www.legis.la.gov/Legis/Law.aspx?d=727112Requires the use of clinical practice guidelines or peer-reviewed articles to develop a step therapy protocol. An override exception request must be granted if the patient has previously tried the preferred drug and it was discontinued due to lack of efficacy, diminished effect, or an adverse event; the drug is reasonably expected to be ineffective based on the known characteristics of the patient and the drug; the drug is contraindicated or is likely to cause an adverse reaction or harm; the patient is currently receiving a positive therapeutic outcome from another drug; the drug is not in the best interest of the patient; or, in the case of a postpartum drug, the preferred drug is not indicated by the U.S. FDA for that use. Exception requests must be determined within 72 hours, or within 24 hours in exigent circumstances. These protections apply to Medicaid.
MAINEMaine Revised Statutes Title 24-A - Maine Insurance Code, Chapter 56-A - Health Plan Improvement Act, Subchapter 1- Health Plan Requirements, § 4320-N. Step Therapyhttps://legislature.maine.gov/statutes/24-a/title24-Asec4320-N.htmlStep therapy protocols must be based on clinical review criteria or peer-reviewed publications. There must be a clear, readily accessible, and convenient process to request an override exception. An exception must be granted if the drug is contraindicated, likely to cause an adverse reaction, or cause harm; the patient has tried the preferred drug before and it was discontinued due to lack of efficacy, diminished effect, or an adverse event; the drug is reasonably expected to be ineffective based on the known characteristics of the patient and the drug; the drug is not in the best interest of the enrollee; the patient is currently stable on a drug chosen by the provider; or the drug selected by the provider is to treat a serious mental illness. Override exception requests must be granted within 72 hours or 2 business days—whichever is shorter—or within 24 hours under exigent circumstances.H.P. 111-L.D. 178 - An Act Regarding Coverage for Step Therapy for Metastatic Cancer (starting January 1, 2026, insurers may not require patient to use a step therapy protocol before covering a prescription drug approved by the US FDA)https://legislature.maine.gov/backend/App/services/getDocument.aspx?documentId=120734
MARYLANDMaryland Code, Insurance § 15-142 - Step Therapyhttps://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gin§ion=15-142&enactments=falseAn override exception request will be granted if the step therapy drug has not been approved by the FDA for the condition being treated, or if a provider provides documentation that the prescription drug was ordered within the last 180 days and determined to be effective in treating the insured. An exception will also be granted if the preferred drug is used to treat the patient's stage 4 metastatic cancer in a manner indicated by the NCCN and supported by peer-reviewed medical literature, or if the drug is used to treat a symptom or side effect of stage 4 advanced metastatic cancer and its use is consistent with best practices and supported by peer-reviewed literature. An exception must also be granted if the drug is insulin or an insulin analog used to treat Type 1, Type 2, or gestational diabetes. There must also be a process to request an exception if the step therapy drug is contraindicated or will likely cause an adverse effect; is expected to be ineffective based on the known characteristics of the patient and the drug; the patient is stable on another medication; or the patient previously tried the same or similar drug but it was discontinued due to lack of efficacy, diminished effect, or an adverse event.
MASSACHUSETTSHouse Bill No. 4929; An Act Relelated to Step Therapy & patient saftey.https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXVII/Chapter118E/Section51ARequires the use of clinical review criteria to establish a step therapy protocol. Requires a clear, readily accessible, and convenient process to request an exception if the drug is contraindicated or likely to cause an adverse reaction or physical harm; the step therapy drug is expected to be ineffective based on the known characteristics of the patient and the drug; the patient has previously tried the same or a similar step therapy drug and it was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event; or the patient is stable on a prescription drug prescribed by the health care provider and switching drugs will likely cause an adverse reaction or harm. Exception requests must be decided within three business days, or within 24 hours if additional delay would result in significant risk to the patient’s health or well-being.
MICHIGAN
MINNESOTA2024 Minnesota Statutes 62Q.184 Step Therapy Overridehttps://www.revisor.mn.gov/statutes/cite/62Q.1841Requires health plans to establish a step therapy protocol using evidence-based and peer-reviewed clinical practice guidelines. Insurers must make the step therapy override process easily accessible on their website. Insurers must grant a step therapy exception request if the step therapy drug is contraindicated; if, due to a documented adverse event with previous use or a documented medical condition (including a comorbid condition), the drug is likely to cause an adverse reaction to the enrollee, decrease functioning, or cause harm; if the patient has tried the drug or a similar drug but it was discontinued due to lack of effectiveness or an adverse event (however, for Medicaid patients, a similar drug may be prescribed if supported by evidence-based and peer-reviewed clinical practice guidelines, the FDA label, or drug manufacturer information); or if the patient is currently stable on another medication and the step therapy drug is expected to be ineffective or cause harm to the enrollee based on the known characteristics of the patient or the drug.
MISSISSIPPI2018 Mississippi Code Tile 83 - Insurance, Chapter 9 - Accident, Health, and Medicare Supplemen Insurance Accident and Health Insurance § 83-9-3 - Process by which prescribing practitioner may request override of restriction on medication restricted for use by insurer step therapy or fail-first protocol; circumstances under which insurer to grant override.https://advance.lexis.com/documentpage/?pdmfid=1000516&crid=39a00e1f-9495-458b-bd31-31edcefac6af&config=00JABhZDIzMTViZS04NjcxLTQ1MDItOTllOS03MDg0ZTQxYzU4ZTQKAFBvZENhdGFsb2f8inKxYiqNVSihJeNKRlUp&pddocfullpath=%2Fshared%2Fdocument%2Fstatutes-legislation%2Furn%3AcontentItem%3A6BV9-6713-RRXS-N04F-00008-00&pdcontentcomponentid=234190&pdteaserkey=sr0&pditab=allpods&ecomp=6s65kkk&earg=sr0&prid=6ff969a5-ce69-4bfc-a23a-5963101a7bbcRequires insurers to grant step therapy exception request if the patient's provider demonstrates that the required drug has been ineffective in the patient's treatment, is reasonably expected to be ineffective based on the characteristics of the patient and drug, or will likely cause harm to the patient. Limits step therapy requirement to a maximum of thirty days with possible extension of up to seven additional days.
MISSOURITitle XXIV - Business and Financial Institutions, Chapter 376 - Business and Financial Institutions, § 376.2034 - Restriction on step therapy protocol, patient to have access to override exception determination - procedure.https://revisor.mo.gov/main/OneSection.aspx?section=376.2034Requires insurer to have clear, convenient, and readily accessible process to request a step therapy override exception determination; requires insurer to grant step therapy exception request if: the patient has tried the required drug and it was discontinued due to lack of effectiveness or adverse effect, or if the patient’s provider attests that coverage of the prescribed drug is necessary to save the patient’s life.
MONTANAMontana Title 33 - Insurance and Insurance Companies, Chapter 22 - Disability Insurance, Part 1 - General Provisions, § 33-22-127. Coverage of oral therapy--opioid use disorderhttps://archive.legmt.gov/bills/mca/title_0330/chapter_0220/part_0010/section_0270/0330-0220-0010-0270.htmlProhibits step therapy requirements for an oral therapy prescription used to treat opioid use disorder.
NEBRASKANebraska Revised Statute 44-7,115. Step-therapy override exception; approval; procedure; effect.https://nebraskalegislature.gov/laws/statutes.php?statute=44-7,115Requires insurer to grant step therapy exception request if the required drug is contraindicated; due to a documented adverse event the step therapy drug is likely to cause an adverse reaction, decrease functioning, or cause harm; the required drug is likely to be ineffective based on the known characteristics of the patient and drug or the patient’s provider’s medical judgement or the patient’s experience with the drug; the patient has tried the required drug and it was discontinued by the patient’s provider for ineffectiveness or an adverse event; or the patient is currently receiving a drug with a positive therapeutic outcome and the patient’s provider indicated that a change is likely to be ineffective or cause harm.Requires a determination within five calendar days for nonurgent requests and within seventy-two hours for urgent requests.
NEVADANRS 695G.1639 Plan covering prescription drug for treatment of medical condition that is part of step therapy protocol: Use of certain guidelines required; establishment of process to request exemption from step therapy protocol required; granting of request; applicability of provisions.https://www.leg.state.nv.us/nrs/NRS-695G.html#NRS695GSec1639Requires managed care organizations to use guidelines based on medical or scientific evidence when developing a step therapy protocol; to have a clear, convenient, and readily accessible process to request an exemption. Exemptions must be granted if the step therapy drug is contraindicated or likely to cause and adverse reaction or harm; is expected to be ineffective based on the characteristics of the patient and the drug; has been tried by the insured, and was discontinued due to lack of efficacy, diminished effect or an adverse event; the step therapy drug is not in the best interest of the insured; or the patient is stable on a prescription drug selected by their provider. Exception requests must be decided within 2 business days or within 24 hours if urgent.
NEW HAMPSHIRE
NEW JERSEYA1825/SCS for S-3533 - Establishes certain guidelines for SHBP, SEHBP, and Medicaid concerning step therapy protocolshttps://pub.njleg.state.nj.us/Bills/2024/A2000/1825_I1.PDFRequires step therapy protocols to be developed using clinical practice guidelines or peer-reviewed publications. A clear, readily accessible, and convenient process to request and exception must be available. An exception shall be granted it the step therapy drug is contraindicated or is likely to cause an adverse reaction or harm; is expected to be ineffective based on the characteristics of the patient and the drug; the patient has tried the required drug or similar drug and it was discontinued due to lack of efficacy or effectiveness, diminished effect, or an 23 adverse event; the required drug is not in the best interest of the patient; or the patient is stable on a prescription drug selected by their provider. Exception requests shall be decided within 72 hours or 24 hours if exigent circumstances exist.
NEW MEXICONew Mexico Statutes § 59A-46-52.1 – Prescription Drug Coverage; Step Therapy Protocolshttps://codes.findlaw.com/nm/chapter-59a-insurance-code/nm-st-sect-59a-46-52-1/#:~:text=Insurance%20Code%20%C2%A7%2059A%2D46%2D52.1.,protocols%3B%20clinical%20review%20criteria%3B%20exceptions&text=(5)%20take%20into%20account%20the,atypical%20patient%20populations%20and%20diagnoses.Requires insurers to have a clear, readily accessible and convenient process to request a step therapy override exception determination. Insurers must grant exception if the required drug is contraindicated or will likely cause harm to the patient, the required drug is expected to be ineffective based on the known characteristics of the patient and drug, the patient has tried the required drug or drugs in the same pharmacologic class with the same mechanism of action while on their current or previous insurance and that drug was discontinued because inefficacy or adverse reaction, the required prescription drug is not in the best interest because use is expected to create a significant barrier to care or worsen a comorbid condition of the patient or decrease the patient’s ability to perform daily functional activities. Requires determination within the lesser of seventy-two hours for nonurgent requests and within twenty for hours for urgent requests.
NEW YORKCosolidated Laws of New Yor, Chapter 45 - Public Health, Article 49 - Utilization Review and External Appeal, Title 1 - Certification of Agents and Utilization Review Process, § 4903 – Utilization review determinationshttps://www.nysenate.gov/legislation/laws/PBH/4903Requires insurer to grant step therapy exception request if the patient's provider demonstrates that: the required prescription drug is contraindicated or likely to cause harm to the patient, the required prescription drug is likely to be ineffective based on the known history and conditions of the patient and the required prescription drug, the patient had previously tried the required drug or a drug in the same pharmacological class with the same mechanism of action that that drug was discontinued for lack of efficacy or adverse event, or the patient is stable on their currently prescribed drug. Requires an exception determination within seventy-two hours for nonurgent requests and within twenty-four hours for urgent requests.
NORTH CAROLINANorth Carolina General Statutes § 58-3-221 - Access to Nonformulary and Restricted Access Prescription Drugshttps://www.ncleg.gov/EnactedLegislation/Statutes/HTML/BySection/Chapter_58/GS_58-3-221.htmlRequires insurers to allow providers to obtain non-formulary drugs or bypass a required sequence of drugs if the drug is medically necessary, appropriate, and covered by the patient’s current health benefit plan. This applies if the patient has tried the required drug, the required drug has been ineffective, or the required drug is reasonably expected to be harmful to the patient. Requires an exception determination within seventy-two hours for non-urgent requests and twenty-four hours for urgent requests.
NORTH DAKOTANorth Dakota Century Code Chapter 19-01.01 - North Dakota Food, Drug, and Cosmetic Act, § 19-02.1-16.3 - Pharmacy Benefits Managers–Step Therapy Protocols - Limitations.https://www.legis.nd.gov/cencode/t19c02-1.pdf#nameddest=19-02p1-16p3Insurers or pharmacy benefits managers may not require step therapy protocols for coverage of FDA approved prescription drugs for the treatment of metastatic cancer and usage of the drug is consistent with FDA approved indications or is supported by peer-reviewed medical literature.
OHIOOhio Revised Code, Title 30 - Insurance, Chapter 3901 Superintendant of Insurance, § 3901.832 - Step therapy exemption.https://codes.ohio.gov/ohio-revised-code/section-3901.832Requires insurers to grant exception to step therapy protocols if the required drug is contraindicated for the patient according to FDA prescribing information, the patient has previously tried the required drug and it was discontinued for lack of efficacy or adverse effect, or the patient is stable on their current prescription drug with an exception for pharmaceutical alternatives per the FDA orange or purple book. Requires an exception determination within 10 calendar days for nonurgent requests and within 48 hours for urgent requests.Ohio Revised Code § 5164.7512 - Step therapy exemption process (outlines exemption process for Medicaid patients)https://codes.ohio.gov/ohio-revised-code/section-5164.7514
OKLAHOMAOklahoma Statutes Title 63. Public Health and Safety, §63-7330. Process to request exception to treatment step therapy protocol — Circumstances requiring an exception.https://law.justia.com/codes/oklahoma/title-63/section-63-7330/Requires insurers to grant exception to step therapy protocols if the patient’s provider states that the required drug is contraindicated or will likely cause harm to the patient, the required drug is expected to be ineffective based on the known characteristics of the patient and drug, the patient has previously tried the required drug and it was discontinued for lack of efficacy or an adverse event, the required drug is not in the best interest of the patient based on medical necessity, or the patient is stable on their current drug. Requires exception determination within 72 hours for nonurgent requests and within 24 hours for urgent requests.
OREGONOregon Revised Statutes, Volume 18 - Financial Institutions, Insurance, Title 56 - Insurance, Chapter 743B - Health Benefit Plans: Individual & Group, § 743B.602 - Step Therapyhttps://oregon.public.law/statutes/ors_743b.602Requires insurers to grant exception to step therapy protocols if the patient’s provider submits evidence establishing that: the required drug is contraindicated or will cause a clinically predictable adverse reaction, the required drug is expected to be ineffective based on the known characteristics of the patient and drug, the patient has previously tried the required drug or a drug in the same pharmacological class or a drug with the same mechanism of action and that drug was discontinued for lack of efficacy or adverse effect, the patient has experienced a positive therapeutic outcome from their current drug for at least ninety days, or the required drug is not in the best interest of the patient based on medical necessity. Requires exception determination within the later of seventy-hours or two business days for urgent requests and within one business day for urgent requests.Oregon Revised Statutes, Vol. 18, Title 56, Chap. 743A. Health Ins.: Reimbursement of Claims, §743A.067 - Reproductive Health Services (prohibits use of step therapy for medically appropriate covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration).https://oregon.public.law/statutes/ors_743a.067Oregon Revised Statutes, Vol. 11, Title 34, Chap. 414 Med. Assistance, § 414.772 -Limits on use of step therapy (requires coordinated care organizations - including those that provide Medicaid or Medical Assistance - to provide clear, easily accessible explanations of clinical criteria used for each step therapy protocol, the procedure by which a provider may submit their rationale for determining step therapy is not appropriate, and documentation required to review the appropriateness of step therapy).https://oregon.public.law/statutes/ors_414.772
PENNSYLVANIAPennsylvania Unconsolidated Statutes, 1921 Act 284 Chapter 21 Section 56 §2156https://www.palegis.us/statutes/unconsolidated/law-information/view-statute?SESSYR=1921&SESSIND=0&ACTNUM=0284.&SMTHLWIND=&CHPT=021.&SCTN=056.&SUBSCTN=000.Insurers or Medical Assistance/CHIP managed care plans must consider step therapy criteria as part of the plan's prior authorization process. Does not guarantee exceptions but requires exception requests to be based on an individual patient's clinical condition and consider at least all of the following: contraindications, including adverse reactions; clinical efficacy of each required prerequisite; expected clinical outcomes of the requested drug; and whether the patient has previously undergone step therapy. The timeframes for determination are the same as that for prior authorization review.
*PUERTO RICOLaws of Puerto Rico, Title 26 - Insurance, Subtitle 3 - Puerto Rico Health Insurance Code, Chapter 102 - Prescription Drug Management, §9047 - Medical exceptions approval process requirements and procedureshttps://law.justia.com/codes/puerto-rico/title-twenty-six/subtitle-3/chapter-102/9047/?utm_source=chatgpt.comHealth insurance organizations or issuers that include a step therapy requirement must establish and maintain a medical exception process that may only be used if the step therapy drugs have been ineffective; clinical and other characteristics of the patient and step therapy drug make it likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; the step therapy drug is likely to cause an adverse reaction or harm; the patient was at the top level of step therapy under another plan. Exception requests must be decided as quickly as possible but not later than 72 hours after the request or 36 hours for controlled drugs; patients are entitled to a 30 day supply of the prescribed drug if the insurer fails to respond.
RHODE ISLANDRhode Island General Laws, Chapter 27-18.9 - Administrative and non-administrative benefit determination procedural requirementshttps://webserver.rilegislature.gov/BillText/BillText25/SenateText25/S0116.pdfRequires insurers to create a clear, easily accessible, and convenient process for healthcare professionals to submit exception requests online. Insurers must grant an exception and provide immediate coverage of a medication if the step therapy drug is: contraindicated or expected to cause an adverse reaction; has been tried and found ineffective; will delay or prevent medically necessary care; or will disrupt the patient's current effective drug regimen. Insurer must decide the exception request within 72 hours of receive or within 24 hours if urgent.
SOUTH CAROLINA
SOUTH DAKOTASouth Dakota Codified Laws Chapter 58 - Insurance, §17H - Untilization Review and Benefit Determinations, §§ 58-17H-53 to 55 - Step therapy protocols - process - override exceptionshttps://sdlegislature.gov/Statutes/58-17H-53Requires insurers to use evidence-based and peer-reviewed clinical practice guidelines when establishing a step therapy protocol. Requires an insurer to provider a clear, readily accessible, and convenient process to request a step therapy override exemption that is easily accessible on the insurer's website. Requires step therapy override exceptions if the required drug is contraindicated or likely to cause harm to the patient or decrease their ability to have reasonable functional ability in performing daily ability, the required drug is expected to be ineffective based on the known characteristics of the patient and drug, the patient has previously used the drug and it was discontinued because a lack of effectiveness, or the patient is receiving a positive therapeutic outcome on their current drug. Requires exception determination within 5 calendar days for nonurgent requests and within 72 hours for urgent requests.
TENNESSEETennessee Code, Title 56 - Insurance, Chapter 7 - Policies and Policyholders, Part 35 - Step Therapy Protocol, §§3501 to 3504.https://advance.lexis.com/documentpage/?pdmfid=1000516&crid=488f7a2c-df42-4d83-bebe-5da7a5cc3611&nodeid=ACEAAHABJAAB&nodepath=%2FROOT%2FACE%2FACEAAH%2FACEAAHABJ%2FACEAAHABJAAB&level=4&haschildren=&populated=false&title=56-7-3501.+Part+definitions.&config=025054JABlOTJjNmIyNi0wYjI0LTRjZGEtYWE5ZC0zNGFhOWNhMjFlNDgKAFBvZENhdGFsb2cDFQ14bX2GfyBTaI9WcPX5&pddocfullpath=%2Fshared%2Fdocument%2Fstatutes-legislation%2Furn%3AcontentItem%3A65PC-YR60-R03K-925N-00008-00&ecomp=6gf5kkk&prid=74430980-3690-4c30-ad97-f2d77cf367faRequires group health carriers to provide a clear, readily accessible, and convenient process to request a step therapy exception that's easily accessible on their website; exceptions must be granted if: the step therapy drug is contraindicated; will likely cause an adverse reaction or harm, the drug is expected to be ineffective; the drug is not in the best interest of the patient because it is expected to cause a significant barrier to adherence or compliance with a patient's plan of care, worse a comorbid condition, or decrease the patient's ability to maintain functional ability; or the patient is current stable on another medication and change is expected to be ineffective or cause harm; exceptions must be decided using the same timeframes for other utilization review requirements. Does not apply to TennCare, CoverKids, or Access Tennessee healthcare programs.
TEXASTexas Insurance Code, Title 8 - Health Insurance and Other Health Coverages, Subtitle E - Benefits Payable Under Health Coverages, Chapter 1369 - Benefits Related to Prescription Drugs and Devices and Related Services, Subchapter A - Coverage of Prescription Drugs in General, § 1369.0545-0546 - Step Therapy Protocol and Exception Requesthttps://statutes.capitol.texas.gov/Docs/IN/htm/IN.1369.htm#1369.0546Requires health benefit plan issuers to develop step therapy protocols in accordance with clinical guidelines and peer-reviewed research. Requires insurers to grant exception to step therapy protocols if the patient’s provider submits a written statement that the required drug is contraindicated or is likely to cause harm to the patient or is likely to be ineffective based on the known characteristics of the patient and drug, the patient previously discontinued taking the required drug or another prescription in the same pharmacologic class or with the same mechanism of action because the drug was ineffective or an adverse event, the required drug is expected to cause a significant barrier to care or worsen a comorbid condition of the patient or decrease the patient’s ability to achieve reasonable functional ability in daily activities. Requires exception determination within 72 hours for nonurgent requests and within 24r hours for urgent requests.
UTAHUtah Code, Title 26B Utah Health and Human Services Code, Chapter 3 Health Care - Administration and Assistance, Part 1 Health Care Assistance, Section 104 Medicaid drug program - Preferred drug list, §§26B-3-105(3)(A)(iii)https://le.utah.gov/xcode/Title26B/Chapter3/26B-3-S105.htmlUtah's Medicaid program prohibits use of step therapy for immunosuppressive drugs without the written or oral consent of the health care provider and the patient.
VERMONTVermont Statutes, Title 8 - Banking and Insurance, Chapter 107 - Health Insurance, Subchapter 1 - Generally, § 4089i – Prescription Drug Coveragehttps://legislature.vermont.gov/statutes/section/08/107/04089iProhibits insurers from requiring patients to fail the same drug more than once for step therapy protocols. Prohibits use of step therapy for prescriptions that treat substance use disorders. Requires exceptions to step therapy protocols if the step therapy drug is contraindicated or will likely cause an adverse reaction or harm; is expected to be ineffective; the same drug or another drug in the same pharmacologic class or mechanism of action has been tried and discontinued due to lack of efficacy, diminished effect, or an adverse event; the insured is stable on a drug; or step therapy is not in the patient's best interests becuase it will pose a barrier to adherence, likely worsen a comordid condition, or likely decrease the patient's functional ability. Timeframe to decide exception request is the same as that for prior authorization.
VIRGINIAVirginia Code § 38.2-3407.9:05 – Step therapy protocolshttps://law.lis.virginia.gov/vacode/title38.2/chapter34/section38.2-3407.9:05/Requires insurers to grant exception to step therapy protocols if the patient’s provider states that the required drug is contraindicated or is likely to be ineffective based on the known characteristics of the drug, the patient has tried the required drug and it was discontinued because a lack of efficacy or an adverse event, or the patient is currently receiving a positive therapeutic outcome on a prescription drug recommended by their provider. Requires exception determination within 72 hours for nonurgent request and within 24 hours for urgent requests.
WASHINGTONRevised Code of Washington, § 48.43.420 Prescription Drug Utilization Management—Exception request process—Conditions, requirements, and time frames for approval or denial of requests—Emergency fill coverage—Notice of new policies and procedures.https://app.leg.wa.gov/RCW/default.aspx?cite=48.43.420Requires insurers to grant exception to step therapy protocols if the required drug is contraindicated or will likely cause a predictable adverse reaction or expected to be ineffective based on the known characteristics of the patient and drug, the patient has previously tried the required drug or a drug in the same pharmacologic class or a drug with the same mechanism of action and it was discontinued because a lack of effectiveness or an adverse event, the patient is currently experiencing a positive therapeutic outcome on a drug recommended by the patient's provider and changing drugs would may cause harm to the patient, or the required drug is not in the best interest of the patient because it would create a barrier to care, negatively impact a comorbid condition of the patient, create a clinically predictable negative drug interaction or decrease the patient’s ability to maintain reasonable daily function. Requires exception determination within 3 business days for nonurgent requests and within 1 business day for urgent requests.
WEST VIRGINIAWest Virginia Code: §33-16-3aa - Step Therapyhttps://code.wvlegislature.gov/33-16-3AA/Requires insurers to grant exceptions to step therapy protocols if the required drug is contraindicated or expected to be ineffective based on the known characteristics of the patient and the drug; the patient has previously tried the required drug and it was discontinued due to a lack of effectiveness or an adverse event; the required drug is not in the best interest of the patient based on medical appropriateness; or the patient is currently stable on a drug recommended by the patient’s provider. Requires an exception determination within seventy-two hours for non-urgent requests and within twenty-four hours for urgent requests.
WISCONSINWisconsin Statutes § 632.866 – Step Therapy Protocolshttps://docs.legis.wisconsin.gov/statutes/statutes/632/vi/866Requires insurers to grant exception to step therapy protocols if:the step therapy drug is contraindicated or, due to a prior adverse event with a previous use or documented medical condition is likely to do any of the following: cause a serious adverse reaction, decrease functional ability, or cause harm; or, the step therapy drug is expected to be ineffective based on clinical evidence or medical and scientific evidence, or the known clinical characeristics of the patient or the drug. Requires exception decision within 3 business days for nonurgent requests or by the end of the next business day for urgent requests.
WYOMINGWyoming Statutes Annotated, Title 26 - Insurance Code, Chapter 55 - Ensuring Transparency in Prior Authorization Act, § 26-55-111 - Continuity of care for enrolleeshttps://advance.lexis.com/documentpage/?pdmfid=1000516&crid=1fea1cf0-c13a-4358-a59d-400714f9b22b&config=00JABmMTEzODA5Zi0wOWExLTQ3NTAtOThmNy0xYjc5ZjUwYzRkZmIKAFBvZENhdGFsb2f3sjqEYfYX7EMD8yWYBYCu&pddocfullpath=%2Fshared%2Fdocument%2Fstatutes-legislation%2Furn%3AcontentItem%3A6BHY-FK83-RRPV-P2MR-00008-00&pdcontentcomponentid=234174&pdteaserkey=sr0&pditab=allpods&ecomp=6s65kkk&earg=sr0&prid=6273d2c5-2cb0-45b5-8f51-21b4cc3478acProvides that a patient cannot be required to repeat a step therapy protocol if they previously tried the step therapy drug or another in the same pharmacologic class and that drug was discontinued due to lack of efficacy, an adverse event, or contraindication; written documentation of the clinical need for the prescribed drug and prior completion of step therapy protocols may be required.
*GUAM
LAST UPDATE9/20228/20258/20258/2025

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