SF 2897 establishes a process for an enrollee or a prescribing health care provider to access in order to be able to request an override to step therapy protocol that has been established by the enrollee’s health plan company.

Section 1 (62Q.184) establishes the step therapy override.

Subd. 1 defines the following terms: clinical practice guideline; clinical review criteria; health plan company; step therapy protocol; and step therapy override. The definition of a health plan company specifies that this does not include a managed care plan or county-based purchasing plan or an integrated health partnership participating in medical assistance or MinnesotaCare.

Subd. 2 requires the health plan company when establishing a step therapy protocol to consider available recognized evidence-based and peer-reviewed clinical practice guidelines.  Requires a health plan company to provide to an enrollee upon request, the clinical review criteria that is applicable to a specific prescription drug.

Subd. 3, paragraph (a), requires that if a health plan company restricts coverage for a prescription drug for the treatment of a medical condition by requiring the use of a step therapy protocol, enrollees and prescribing providers must have access to a process to request a step therapy override.  The override process must be accessible through the health plan company’s Web site.  Specifies the conditions where a health plan company must grant an override.

Paragraph (b) states that once an override has been granted, the health plan company must authorize coverage for the prescription drug if the drug is covered under the enrollee’s health plan.

Paragraph (c) permits the enrollee or the enrollee’s prescribing health care provider if designated by the enrollee, to appeal a denial of a step therapy override using the complaint process established under sections 62Q.68 to 62Q.73.

Paragraph (d) If a health plan company denies an override request or an appeal of a denial, the health plan company’s decision must state why the override request did not meet the condition cited by the override request and must provide information on how to request an external review under section 62Q.73.

Paragraph (e) requires a health plan company to respond to an override request or an appeal within five days of receipt of a complete request, or within 72 hours if there are exigent circumstances.  If a health plan company does not respond within these time limits, the request is granted and is binding on the health plan company.

Paragraph (f) requires step therapy override requests to be accessible to health care providers and providers must be able to submit the requests electronically through secure electronic transmission.

Paragraph (g) states that nothing in this section prohibits a health plan company from requesting relevant documentation from an enrollee’s medical record in support of a step therapy override request or from requiring an enrollee to try a generic equivalent drug or a biosimilar prior to providing coverage for the equivalent branded prescription drug,

Paragraph (h) specifies that this section is not to be construed to allow the use of a drug sample for the primary purpose of meeting the requirements for a step therapy override.