Description

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:

1. Is contraindicated or will likely cause an adverse reaction to the patient.
2. 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.
3. Is not in the best interest of the patient, based on medical appropriateness.
4. Will interrupt the patient’s stability on a prescription drug selected by their health care provider.
5. 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.

Click here to read the full bill text and status.