23 CAR § 149-106 – Access to step therapy protocol exception process

(a) If coverage of a prescription drug for the treatment of any medical condition is restricted for use by a healthcare insurer, health benefit plan, or utilization review organization through the use of a step therapy protocol, a patient and prescribing healthcare provider shall have access to a clear, readily accessible, and convenient process to request a step therapy protocol exception.
(b)
1. (1) A healthcare insurer, health benefit plan, or utilization review organization may use its existing medical exceptions process to satisfy the requirement under subsection (a) of this section.
2. (2) The existing medical exceptions process shall be easily accessible on the website of the:
  1. (A) Healthcare insurer;
  2. (B) Health benefit plan; or
  3. (C) Utilization review organization.
3. (3) Upon request, a healthcare insurer, health benefit plan, or utilization review organization shall disclose to a prescribing healthcare provider all rules and clinical review criteria related to the step therapy protocol, including without limitation the specific information and documentation that is required to be submitted by a prescribing healthcare provider or patient to the healthcare insurer, health benefit plan, or utilization review organization to be considered a complete step therapy protocol exception request.