§ 38a-544 — Prescription drug coverage. Mail order pharmacies. Step therapy use.

(a) No insurance company, hospital service corporation, medical service corporation, health care center or other entity delivering, issuing for delivery, renewing, amending or continuing a group health insurance policy or contract that provides coverage for prescription drugs may: (1) Require any person covered under such policy or contract to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for such drugs; or (2) Require, if such insurance company, hospital service corporation, medical service corporation, health care center or other entity uses step therapy for such drugs, the use of step therapy (A) for any prescribed drug for longer than thirty days, (B) for a prescribed drug for cancer treatment for an insured who has been diagnosed with stage IV metastatic cancer provided such prescribed drug is in compliance with approved federal Food and Drug Administration indications, or (C) for the period commencing January 1, 2024, and ending January 1, 2027, inclusive, for the treatment of schizophrenia, major depressive disorder or bipolar disorder, as defined in the most recent edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders”. (3) At the expiration of the time period specified in subparagraph (A) of subdivision (2) of this subsection or for a prescribed drug described in subparagraph (B) or (C) of subdivision (2) of this subsection, an insured's treating health care provider may deem such step therapy drug regimen clinically ineffective for the insured, at which time the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract. If such provider does not deem such step therapy drug regimen clinically ineffective or has not requested an override pursuant to subdivision (1) of subsection (b) of this section, such drug regimen may be continued. For purposes of this section, “step therapy” means a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition are to be prescribed. (b) (1) Notwithstanding the sixty-day period set forth in subdivision (2) of subsection (a) of this section, each insurance company, hospital service corporation, medical service corporation, health care center or other entity that uses step therapy for such prescription drugs shall establish and disclose to its health care providers a process by which an insured's treating health care provider may request at any time an override of the use of any step therapy drug regimen. Any such override process shall be convenient to use by health care providers and an override request shall be expeditiously granted when an insured's treating health care provider demonstrates that the drug regimen required under step therapy (A) has been ineffective in the past for treatment of the insured's medical condition, (B) is expected to be ineffective based on the known relevant physical or mental characteristics of the insured and the known characteristics of the drug regimen, (C) will cause or will likely cause an adverse reaction by or physical harm to the insured, or (D) is not in the best interest of the insured, based on medical necessity. (2) Upon the granting of an override request, the insurance company, hospital service corporation, medical service corporation, health care center or other entity shall authorize dispensation of and coverage for the drug prescribed by the insured's treating health care provider, provided such drug is a covered drug under such policy or contract. (c) Nothing in this section shall (1) preclude an insured or an insured's treating health care provider from requesting a review under sections 38a-591c to 38a-591g , inclusive, or (2) affect the provisions of section 38a-518i . See Sec. 38a-510 for similar provisions re individual policies.

Legislative History

(P.A. 89-374; P.A. 14-118, S. 2; P.A. 17-228, S. 2; P.A. 23-204, S. 226.) History: P.A. 14-118 amended Subsec. (a) to designate existing provision re mail order pharmacy as Subdiv. (1) and add Subdiv. (2) re step therapy, deleted former Subsec. (b) re application of section, added new Subsec. (b) re step therapy override, added Subsec. (c) re effect of section on Secs. 38a-591c to 38a-591g and 38a-518i, and made technical and conforming changes, effective January 1, 2015; P.A. 17-228 amended Subsec. (a) to designate existing provisions re prescribed drug for longer than 60 days as Subpara. (A), and add Subpara. (B) re prescribed drug for cancer treatment in Subdiv. (2), designate existing provisions re deeming step therapy drug regimen clinically ineffective as Subdiv. (3) and amended same to add reference to Subdiv. (2), and make technical changes, effective January 1, 2018; P.A. 23-204 amended Subsec. (a) by substituting 30 days for 60 days in Subdiv. (2)(A), adding Subdiv. (2)(C) re step therapy prescription drug prohibition for treatment of schizophrenia, major depressive disorder and bipolar disorder from January 1, 2024, to January 1, 2027, and made technical and conforming changes, effective January 1, 2024.