SB 959 - This act specifies additional circumstances under which a patient shall be granted an exception to a step therapy protocol required by a health carrier for coverage of a prescription drug. Under the act, a step therapy override exception determination shall be granted if: • A delay in treatment would lead to severe or irreversible consequences, and the treatment otherwise required under the step therapy protocol is reasonably expected to be ineffective based upon patient and treatment characteristics;
• Any treatments otherwise required under the step therapy protocol are contraindicated for the patient or have caused or are likely to cause an adverse reaction or other physical harm to the patient;
• Any treatment otherwise required under the step therapy protocol has prevented, will prevent, or is likely to prevent a patient from achieving or maintaining reasonable and safe functional ability in performing occupational responsibilities or activities of daily living, as defined by federal law; or
• The patient is stable for his or her disease or condition on the prescription drug or drugs selected by the prescribing health care provider and has previously received approval for coverage of the relevant drug or drugs under his or her current or previous health coverage.
ERIC VANDER WEERD