New Hampshire HB 1638: creating a bypass mechanism for health insurer step therapy protocols when medically necessary.

Bill Text

HB 1638-FN - AS INTRODUCED

2026 SESSION

 26-3029

 07/08

HOUSE BILL 1638-FN

AN ACT creating a bypass mechanism for health insurer step therapy protocols when medically necessary.

SPONSORS: Rep. Nagel, Belk. 6; Rep. Lundgren, Rock. 16; Rep. W. MacDonald, Rock. 16; Rep. Miles, Hills. 12; Rep. M. Pearson, Rock. 34; Rep. L. Walsh, Rock. 15; Rep. Woods, Merr. 30; Sen. Avard, Dist 12; Sen. Rosenwald, Dist 13

COMMITTEE: Commerce and Consumer Affairs

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ANALYSIS

 This bill creates a bypass mechanism for health insurer step therapy protocols when medically necessary.

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Explanation: Matter added to current law appears in bold italics.

 Matter removed from current law appears [in brackets and struckthrough.]

 Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.

 26-3029

 07/08

STATE OF NEW HAMPSHIRE

In the Year of Our Lord Two Thousand Twenty-Six

AN ACT creating a bypass mechanism for health insurer step therapy protocols when medically necessary.

Be it Enacted by the Senate and House of Representatives in General Court convened:

 1 New Subdivision; Step Therapy. Amend RSA 420-J by inserting after section 26 the following new subdivision:

Step Therapy

 420-J:27 Definitions. As used in this subdivision:

 I. "Advanced, metastatic cancer" means a cancer that has spread from the primary or original site of the cancer to nearby tissues, lymph nodes, or other areas or parts of the body.

 II. "Associated conditions" means the symptoms or side effects associated with advanced, metastatic cancer or its treatment and which, in the judgment of the health care practitioner, further jeopardizes the health of a patient if left untreated.

 III. "Clinical practice guidelines" means a systematically developed statement to assist prescriber and enrollee decisions about appropriate health care for specific clinical circumstances and conditions.

 IV. "Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by a carrier or utilization review organization to determine the medical necessity and appropriateness of health care services.

 V. "Medically necessary," when using in the context of health services and supplies, means appropriate, under the applicable standard of care, to improve or preserve health, life or function; to slow the deterioration of health, life or function; or for the early screening, prevention, evaluation, diagnosis or treatment of a disease, condition, illness or injury.

 VI. "Pharmaceutical sample" means a unit of a prescription drug that is not intended to be sold and is intended to promote the sale of the drug.

 VII. "Serious mental illness" means a mental disorder, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, that results in serious functional impairment that substantially interferes with or limits one or more major life activities.

 VIII. "Stable on a prescription drug" means, with respect to an enrollee, receiving a positive therapeutic outcome on a prescription drug selected by the enrollee's health care provider for the enrollee's medical condition.

 IX. "Step therapy override exception determination" means a determination based on a review of an enrollee's or prescriber's request for an override, along with supporting rationale and documentation, that the step therapy protocol should be overridden in favor of immediate coverage of the health care provider's selected prescription drug.

 X. "Step therapy protocol" means a protocol that establishes a specific sequence in which prescription drugs for a specified medical condition are medically necessary for a particular enrollee and are covered under a pharmacy or medical benefit by a carrier, including self‑administered and physician‑administered drugs.

 XI. "Utilization review organization" means an entity that conducts a utilization review, other than a carrier performing a utilization review for its own health benefit plans.

 420-J:28 Clinical Review Criteria. Clinical review criteria used to establish a step therapy protocol shall be based on clinical practice guidelines that:

 I. Recommend that the prescription drugs be taken in the specific sequence required by the step therapy protocol;

 II. Are developed and endorsed by a multidisciplinary panel of experts that manages conflicts of interest among the members of the writing and review groups by:

 (a) Requiring members to disclose any potential conflicts of interest with entities, including carriers and pharmaceutical manufacturers, and recuse themselves from voting if they have a conflict of interest;

 (b) Using a methodologist to work with wr