California - AB374
Establishes Step Therapy Override Process
February 17, 2015
AB 374 allows a prescribing provider, based on his/her professional judgment, to request a step therapy override determination from a health plan or insurer, on behalf of a patient.
A step therapy override determination request shall be expeditiously granted by the health plan/insurer, if the prescription drug required by the plan:
- Is contraindicated or will likely cause an adverse reaction to the patient.
- Is expected to be ineffective based on the known relevant physical or mental characteristics of the patient and the known characteristics of the prescription drug.
- Is not in the best interest of the patient, based on medical appropriateness.
- Will interrupt the patient’s stability on a prescription drug selected by their health care provider.
- Has not been approved by the federal Food and Drug Administration for the patient’s condition.
“Step therapy override determination” means a determination as to whether a step therapy protocol should apply in a particular patient’s situation, or whether the step therapy protocol should be overridden in favor of immediate coverage of the selected prescription drug.