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Health Insurance State Laws:
Step Therapy

This chart highlights the state laws related to Step Therapy for prescription drug coverage, including information on states that have a consumer protection law, and states that have pending legislation.

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StateState Law Consumer Protection on Step TherapyBrief Description of the State Law ProtectionPending LegislationBrief Description of the Pending Legislation
ALABAMA
ALASKA
ARIZONASenate Bill 1270 (2021) (Codified at Arizona Revised Statutes §§ 20-3651 to -3654)https://apps.azleg.gov/BillStatus/BillOverview/75032Step therapy protocols must be created by either a multidisciplinary panel of experts following research and medical practice or in accordance with peer reviewed publications; insurer must follow and publish a clear and convenient process to request exemptions; exemption must be granted if protocol required drug is contraindicated or will likely cause serious adverse reaction, the drug is expected to be ineffective based on the known characteristics of the patient and drug, the patient has previously tried the drug or a similar drug, the drug is not in the best interest of the patient, or the patient is experiencing a positive therapeutic outcome on their current prescribed drug.
ARKANSASArkansas Code § 23-99-1114 - Limitations on Step Therapyhttps://advance.lexis.com/documentpage/?pdmfid=1000516&crid=77ce30dc-8f7b-4511-b730-fd8f1103774e&nodeid=AAXAADAAVAAWAAF&nodepath=%2FROOT%2FAAX%2FAAXAAD%2FAAXAADAAV%2FAAXAADAAVAAW%2FAAXAADAAVAAWAAF&level=5&haschildren=&populated=false&title=23-79-2104.+Exceptions+%E2%80%94+Transparency.+%5BEffective+January+1%2C+2022.%5D&config=00JAA2ZjZiM2VhNS0wNTVlLTQ3NzUtYjQzYy0yYWZmODJiODRmMDYKAFBvZENhdGFsb2fXiYCnsel0plIgqpYkw9PK&pddocfullpath=%2Fshared%2Fdocument%2Fstatutes-legislation%2Furn%3AcontentItem%3A623Y-B850-R03P-02SS-00008-00&ecomp=8gf5kkk&prid=a7e3486b-0a38-4cf5-ba04-6e8078cb72f6Step therapy protocols must be created by either a multidisciplinary panel of experts following research and medical practice or in accordance with peer reviewed publications; insurer must follow and publish a clear and convenient process to request exemptions; exemption must be granted if protocol required drug is contraindicated or will likely cause serious adverse reaction, the drug is expected to be ineffective based on the known characteristics of the patient and drug, the patient has previously tried the drug or a similar drug, the drug is not in the best interest of the patient, or the patient is experiencing a positive therapeutic outcome on their current prescribed drug; determination required within seventy-two hours for nonurgent exemption requests and twenty-four hours for urgent exemption requests; insurers may not require step therapy for patients with metastatic cancer unless use of the preferred drug is consistent with FDA approved indications, the National Comprehensive Cancer Network indications, or peer-reviewed recognized medical literature.
CALIFORNIA2021 Assembly Bill 347 (to be codified at Health and Safety Code §§ 1367.206, 1367.241).https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202120220AB347Patient may appeal step therapy exception denials to state Independent Medical Review program if denial was for medical necessity or experimental nature of the treatment, or for an emergency/urgent treatment; requires insurers to review requests for step therapy exceptions; requires automatic approval of step therapy exception requests for prescription drugs within seventy-two hours for nonurgent requests and twenty-four hours if there are exigent circumstances.
COLORADOColorado Revised Statutes: § 10-16-145 – Step Therapyhttps://advance.lexis.com/documentpage/?pdmfid=1000516&crid=8df6e399-a9a3-478e-a62d-3639e23fcbcc&nodeid=AAKAARAABAAB&nodepath=%2FROOT%2FAAK%2FAAKAAR%2FAAKAARAAB%2FAAKAARAABAAB&level=4&haschildren=&populated=false&title=Article+16+Health+Care+Coverage&config=014FJAAyNGJkY2Y4Zi1mNjgyLTRkN2YtYmE4OS03NTYzNzYzOTg0OGEKAFBvZENhdGFsb2d592qv2Kywlf8caKqYROP5&pddocfullpath=%2Fshared%2Fdocument%2Fstatutes-legislation%2Furn%3AcontentItem%3A61P5-WPR1-DYDC-J54G-00008-00&ecomp=_g1_9kk&prid=927d3974-436d-4c64-a0e2-00c24efd6732Prohibits step therapy requirements for patients with stage four advanced metastatic cancer unless the preferred drug is consistent with FDA approved indications, the National Comprehensive Cancer Network indications, or peer-reviewed recognized medical literature; insurers may not require step therapy when the patient has tried the step-therapy-required drugs under current or previous health insurance plan and drugs were discontinued for lack of efficacy or adverse effects.
CONNECTICUTConnecticut General Statutes § 38a-510 and § 38a-544 – Step Therapy Usehttps://www.cga.ct.gov/current/pub/title_38a.htmProhibits insurers from requiring step therapy for longer than sixty days or for any stage IV metastatic cancer prescription drug; requires insurers to have override process for step therapy regimens if the patient's health care provider deems the step therapy drug regimen clinically ineffective after sixty days of use.
DELAWARE2016 House Bill 381 (Codified at Delaware Code Title 18, Chapter 33, Subchapter II – Pre-Authorization Transparency § 3381)https://delcode.delaware.gov/title18/c033/sc02/index.htmlRequires insurers to have and publish 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 same class of drug under their current or previous health plan, not in the medically necessary best interest of the patient, or the patient is stable under the prescription drug selected by their provider; requires step therapy exception determination within two business days for nonurgent requests and within twenty-four hours for urgent requests.
*DISTRICT OF COLUMBIA
FLORIDAFlorida Statutes § 627.42393 – Step Therapyhttp://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0600-0699/0627/0627PartIIContentsIndex.html&StatuteYear=2021&Title=%2D%3E2021%2D%3EChapter%20627%2D%3EPart%20IIProhibits insurers from requiring patients to follow step therapy protocol for a prescription drug when 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 instant request.
GEORGIAGeorgia Code § 33-24-59.25 – Step Therapyhttp://www.lexisnexis.com/hottopics/gacode/default.aspStep therapy exceptions must be granted if the required drug: is contraindicated or will likely cause harm to the patient, is expected to be ineffective based on the known condition of the patient and the characteristics of the drug, the patient has tried the required drug or same class of drug under their current or previous health plan, not in the medically necessary best interest of the patient, or the patient is stable under 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 to the patient; requires step therapy exception determination within two business days for nonurgent requests and within twenty-four hours for urgent requests.
HAWAII2021 Senate Bill 218https://www.capitol.hawaii.gov/session2022/Bills/SB218_.PDFProposing prohibiting insurers from requiring step therapy for patients undergoing treatment for stage two through stage four cancer
IDAHO
ILLINOISManaged Care Reform and Patients Rights Act (2000) (Codified at 215 ILCS 134)https://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1265&ChapterID=22Insurers must grant step therapy exception requests if: the required drug is contraindicated, the patient has tried the required drug on their current or previous health plan and the patient’s provider submits evidence of failure or intolerance, or if the patient is stable on a drug currently selected by their provider; requires step therapy exception determination within seventy-two hours for nonurgent requests and twenty-four hours for urgent requests; requests must be granted for at least twelve months.
INDIANAIndiana Code Title 27 Article 13 Chapter 7-23 Step Therapy Protocolhttp://iga.in.gov/legislative/laws/2021/ic/titles/027#27-13-7-23Insurer must publish procedure to request step therapy protocol exception; insurer must grant 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 or a drug in the same pharmacologic class or a drug with the same mechanism of action and the drug was discontinued because of 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 have reasonable function in daily activities; exception request determination required within three business days for nonurgent requests and one business day for urgent requests.
IOWAIowa Administrative Code Chapter 514F.7 - Use of Step Therapy Protocolshttps://www.legis.iowa.gov/docs/code/514F.7.pdfInsurer must grant step therapy exception request if: the required drug is contraindicated or likely to cause 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 under their current or previous insurance and the patient's provider submits evidence of ineffectiveness, or the patient is receiving a positive outcome from a drug selected by their provider; exception request determination required within five calendar days or nonurgent requests and within seventy-two hours for urgent requests.
KANSAS2021 House Bill 2157http://kslegislature.org/li/b2021_22/measures/documents/hb2157_00_0000.pdfProposing to require insurers to provide clinical guidelines for step therapy exception requests and to require insurers to grant exceptions for contraindications, previous use, stability on a current drug
KENTUCKYKentucky Revised Statutes Chapter 304 Subtitle 17A Miscellaneous Provisions § 163 - Override of Restricts on Medication Sequence in Step Therapyhttps://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38715Limits duration of step therapy or fail-first protocol to a maximum of thirty days with possible extension of up to seven days; requires exception request determination within forty-eight hours; insurers must grant exception if patient's provider can demonstrate that the protocol has been ineffective, or is likely to be ineffective based on the patient and drug's known characteristics.
LOUISIANALouisiana Revised Statute § 22:1053 - Requirement for Coverage of Step Therapy Protocolshttp://www.legis.la.gov/legis/Law.aspx?d=727112Insurer must make step therapy override process easily accessible on their website; insurer must grant step therapy override request if the patient’s provider can demonstrate that: the required drug has been ineffective in treating the patient, the required drug is reasonably expected to be ineffective based on the known characteristics of the patient and drug, the preferred drug is contraindicated or will likely cause harm to the patient, the patient is currently receiving a positive therapeutic outcome for the condition under consideration, or the required drug is not in the best interest of the patient based on medical necessity; prohibits step therapy protocols for the treatment of stage-four advanced metastatic cancer or associated condition if the patient’s current drug has an FDA or National Comprehensive Cancer Network indication, or is supported by medical literature; requires determination within seventy-two hours for nonurgent requests and twenty-four hours for urgent requests.
MAINEMaine Revised Statutes Title 24-A § 4320-N – Step Therapyhttps://legislature.maine.gov/legis/statutes/24-A/title24-Asec4320-N.htmlRequires 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 drug 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 of the patient based on medical necessity, or the patient is stable on a drug selected by their provider; requires determination within the lesser of seventy-two hours or two business days for nonurgent requests and within twenty-four hours for urgent requests.
MARYLANDMaryland Code, Insurance § 15-142 Step Therapyhttps://law.justia.com/codes/maryland/2021/insurance/title-15/subtitle-1/section-15-142/Prohibits insurers from imposing step therapy requirements if: the required drug has not been approved by FDA for the medical condition, or the patient's provider shows that the current prescription drug was ordered with the past 180 days and was effective in treating the patient's condition; prohibits insurers from imposing step therapy requirements for FDA approved drugs for treatment of patient's stage four advanced metastatic cancer when use of prescription drug is consistent with FDA approved indication or the National Comprehensive Cancer Network indication.
MASSACHUSETTS2021 Senate Bill 756https://malegislature.gov/Bills/192/S756Proposing requiring insurers to follow clinical criteria for step therapy protocols and requiring insurers to grant exceptions when the required drug is contraindicated, will harm the patient, has been previously tried, or the patient is stable on their current drug
MICHIGAN
MINNESOTAMinnesota Statutes Chapter 62Q Step Therapy Override § 62q.184, Prohibition of Use of Step Therapy for Metastatic Cancer § 62q.1841https://www.revisor.mn.gov/statutes/cite/62Q.1841Requires insurers to make step therapy override process easily accessible on website; insurers must grant step therapy exception request if: the required drug is contraindicated or likely to harm the patient or likely to decrease the functional daily ability of the patient, the patient has tried the required drug and it was discontinued by the patient’s provider for ineffectiveness or an adverse event, 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; prohibits step therapy requirements for patients with stage four advanced metastatic cancer or associated conditions if use of the drug is consistent with FDA or National Comprehensive Care Network indications; requires determination within five days for nonurgent requests and seventy-two hours for urgent requests.
MISSISSIPPIMississippi Code § 83-9-6-36 Prescribing Practitioners Step Therapyhttps://advance.lexis.com/documentpage/?pdmfid=1000516&crid=ce74f58c-f959-4cd1-85bb-adb0f588db53&nodeid=ABRAAHAABAAI&nodepath=/ROOT/ABR/ABRAAH/ABRAAHAAB/ABRAAHAABAAI&level=4&haschildren=&populated=false&title=%c2%a7%2083-9-6.3.%20Standardized%20prior%20authorization%20form%20for%20obtaining%20prior%20authorization%20for%20prescription%20drug%20benefits.&config=00JABhZDIzMTViZS04NjcxLTQ1MDItOTllOS03MDg0ZTQxYzU4ZTQKAFBvZENhdGFsb2f8inKxYiqNVSihJeNKRlUp&pddocfullpath=/shared/document/statutes-legislation/urn:contentItem:8P6B-88V2-8T6X-72HC-00008-00&ecomp=_g1_kkk&prid=bdade22e-8b18-4326-b9f4-a38f321e3cb8Requires 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.
MISSOURIRevised Statutes of Missouri § 376.2034 Restriction on Step Therapy Protocolhttps://revisor.mo.gov/main/OneSection.aspx?section=376.2034&bid=49917Requires 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.
MONTANA
NEBRASKANebraska Revised Statute § 44-7,115 - Step Therapy Override Exceptionhttps://nebraskalegislature.gov/laws/statutes.php?statute=44-7,115Requires insurer to grant step therapy exception request if: the required drug is contraindicated or likely to cause harm to the patient or decrease the patient’s daily functional ability, 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.
NEVADA2021 Senate Bill 290 § 1 Application for Exemption for Step Therapy Protocol for Certain Cancer Patients.https://www.leg.state.nv.us/App/NELIS/REL/81st2021/Bill/7893/OverviewRequires insurers to permit patients with stage three or stage four cancer to apply for exemptions from step therapy protocols by having their provider present the clinical rationale for the exemption; requires insurers to grant step therapy protocol exemptions for patients with stage three or stage four cancer if the required drug has not been effective in treating the cancer, the delay of effective treatment would have severe of irreversible consequences for the patient, the required treatment is contraindicated or is likely to cause the patient harm or is likely to prevent the patient from engaging in daily living activities, or the condition of the patient is stable on their current drug.
NEW HAMPSHIRE
NEW JERSEY2022 Bill A2010https://www.njleg.state.nj.us/bill-search/2022/A2010Proposing that insurers must follow certain criteria when establishing step therapy protocols and requiring that insurers grant exceptions to step therapy protocols when the required drug is contraindicated, will harm the patient, is likely ineffective, or the patient is stable on their current drug
NEW MEXICONew Mexico Statutes § 59A-46-52.1 – Prescription Drug Coverage; Step Therapy Protocolshttps://nmonesource.com/nmos/nmsa/en/item/4438/index.do#!fragment/zoupio-_Toc91761392/BQCwhgziBcwMYgK4DsDWszIQewE4BUBTADwBdoAvbRABwEtsBaAfX2zgE4BGAdgDYuAZg4AmAJQAaZNlKEIARUSFcAT2gBydRIiEwuBIuVrN23fpABlPKQBCagEoBRADKOAagEEAcgGFHE0jAAI2hSdjExIARequires 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 YORKNew New York Public Health Law § 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 nonformulary drugs or bypass a required sequence of drugs if the drug is medically necessary, appropriate, and covered by the current health benefit plan 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 nonurgent requests and twenty-four hours for urgent requests.
NORTH DAKOTANorth Dakota Century Code § 19-02.1-16.3 Pharmacy Benefits Managers–Step Therapy Protocolshttps://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 cancer and usage of the drug is consistent with FDA approved indications or is supported by peer-reviewed medical literature.
OHIOOhio Revised Code § 3901.832 - Step therapy exemptionshttps://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 blook; requires an exception determination within ten calendar days for nonurgent requests and within forty-eight hours for urgent requests.
OKLAHOMAOklahoma Statutes Title 63 § 7310 - Step Therapy Protocolhttp://www.oklegislature.gov/osStatuesTitle.aspxRequires 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 seventy-two hours for nonurgent requests and within twenty-four hours for urgent requests.
OREGONHouse Bill 2517 (2021) (To be codified at Oregon Revised Statutes § 743B.602)https://olis.oregonlegislature.gov/liz/2021R1/Downloads/MeasureDocument/HB2517/EnrolledRequires 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.
PENNSYLVANIA2021-2022 House Bill 225https://www.legis.state.pa.us/cfdocs/billinfo/billinfo.cfm?syear=2021&sind=0&body=H&type=B&bn=0225Proposing limitations on insurers regarding step therapy including requiring insurers to grant exceptions when the required drug is contraindicated, expected to be ineffecitve, the patient has previously tried the drug or a similar drug, or the patient is stable on their current drug
*PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTASouth Dakota Codified Laws § 58-17H-55 Step Therapy Override Exceptionshttps://sdlegislature.gov/Statutes/Codified_Laws/2078684Requires insurers to grant exception to step therapy protocols 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 five calendar days for nonurgent requests and within seventy-two hours for urgent requests.
TENNESSEE2021-2022 House Bill 0677https://wapp.capitol.tn.gov/apps/BillInfo/Default.aspx?BillNumber=HB0677Proposing the imposition of limitations on step therapy protocols and requiring insurers to grant exceptions when the required drug is contraindicated, will harm the patient, is expected to be ineffective, the patient has previously tried the drug or similar drug, or the patient is stable on their current drug
TEXASTexas Insurance Code § 1369.0546 - Step Therapy Protocol Exception Requesthttps://statutes.capitol.texas.gov/Docs/IN/htm/IN.1369.htm#1369.0546Requires 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 seventy-two hours for nonurgent requests and within twenty-four hours for urgent requests.
UTAH
VERMONTVermont Statutes Title 8 § 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.
VIRGINIAVirginia Code § 38.2-3407.9:05 – Step Therapyhttps://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 seventy-two hours for nonurgent request and within twenty-four hours for urgent requests.
WASHINGTONRevised Code of Washington § 48.43.420 Prescription Drug Utilization Managementhttps://app.leg.wa.gov/RCW/default.aspx?cite=48.43.420Requires insurers to grant exception to step therapy protocols if: the require 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 three business days for nonurgent requests and within one business day for urgent requests.
WEST VIRGINIAWest Virginia Code: §33-16-3aa - Step Therapyhttps://code.wvlegislature.gov/33-16-3AA/Requires insurers to grant exception to step therapy protocols if: the required drug is contraindicated or 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 because a lack of effectiveness or an adverse event, the required drug is not in the best interest of the patient based upon medical appropriateness, or the patient is currently stable on a drug recommended by the patient's provider; requires a exception determination within seventy-two hours for nonurgent 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 required drug is contraindicated or likely to cause harm to the patient or decrease the patient’s ability to maintain reasonable daily activity functionality, the required drug is expected to be ineffective based on the characteristics of the patient and drug, the patient has tried the required drug and it was discontinued because of a lack of effectiveness or harm to the patient, or the patient is stable on a drug selected by their provider; requires exception determination within seventy-two hours for nonurgent request and twenty-four hours for urgent requests.
WYOMING
*GUAM
LAST UPDATE9/20229/20229/20229/2022

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