House committee substitute makes the following changes to the 1st edition.
Amends GS 58-50-315 to add that nothing in the Part is to be construed to impact an insurers' ability to substitute a generic drug for a name brand drug.
Makes clarifying and technical changes throughout.
Changes the effective date of the act from October 1, 2015, to January 1, 2016.
Bill Summaries: H821 (2015-2016 Session)
Bill H 821 (2015-2016)Summary date: Apr 29 2015 - View summary
Bill H 821 (2015-2016)Summary date: Apr 17 2015 - View summary
Enacts new Part 8, Administration of Step Therapy Protocols, in Article 50 of GS Chapter 58. Requires clinical review criteria used to establish step therapy protocol to be based on clinical practice guidelines that meet the five specified requirements. Defines step therapy protocol as a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition are medically appropriate for a particular patient and are covered by an insurer or health plan. Requires that the patient and prescribing practitioner have access to a clear and convenient process for requesting a Step Therapy Exception Determination when coverage for a prescription drug is restricted for use by a health benefit plan or utilization review organization through the use of a step therapy protocol. Sets out conditions under which a step therapy override determination request must be expeditiously granted. Requires that when an override determination is granted, the health plan or utilization review organization authorize coverage for the prescribed drug if it is a covered prescription. Effective October 1, 2015, and applies to health benefit contracts issued, renewed, or amended on or after that date.