Step Therapy

SB0515/HB0785

Senate Bill - SB0515 - Status - Click Here

Link to Bill: Health Insurance – Step Therapy or Fail–First Protocol – Revisions

Synopsis: Prohibiting certain insurers, nonprofit health service plans, and health maintenance organizations from imposing a step therapy or fail-first protocol on an insured or an enrollee for certain prescription drugs used to treat a certain mental disorder or condition; and requiring certain insurers, nonprofit health service plans, or health maintenance organizations to establish a certain process for requesting an exception to a step therapy or fail-first protocol.

Sponsored by: Senators Lam

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House Bill - HB0785 - Status - Click Here

Link to Bill - Health Insurance – Step Therapy or Fail–First Protocol – Revisions

Sponsored by: Delegates S. Johnson and White

Approved

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National Psoriasis Foundation

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Additional Information

Maryland’s law currently only allows a patient to override a step therapy protocol if the patient has already been on a drug for 180 days and the prescriber attests that the patient is doing well on the drug. This legislation recognizes there may be other clinical reasons why a patient cannot or should not take a certain drug. Therefore, the legislation will require a carrier to establish a process for requesting an exception to a step therapy protocol if, based on the professional judgement of a prescriber, the prescription drug required to be used by a step therapy protocol

• is contraindicated or will likely cause an adverse reaction, physician harm, or mental harm to the patient; or

• is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug regimen; or

• the patient is stable on a prescription drug selected by their health care provider; or • the patient has already tried a prescription drug in the same pharmacologic class or has the same mechanism of action as the step therapy drug and was discontinued by the prescriber due to lack of efficacy or effectiveness, diminished effect, or an adverse event.

This legislation also exempts from step therapy protocols a prescription drug that is used to treat the insured or enrollee’s mental disorder or condition under certain conditions.