Maryland HB 1359: Health Insurance - Requirements for Establishing Step Therapy Protocol and Requesting Exceptions

Bill Text

EXPLANATION: CAPITALS INDICATE MATTER ADDED TO EXISTING LAW.
[Brackets] indicate matter deleted from existing law.
*hb1359*

HOUSE BILL 1359
C3 0lr3225
CF SB 952
By: Delegates P. Young, Bhandari, Carr, Gilchrist, Kipke, R. Lewis, and Saab
Introduced and read first time: February 7, 2020
Assigned to: Health and Government Operations

A BILL ENTITLED

AN ACT concerning 1

Health Insurance – Requirements for Establishing Step Therapy Protocol and 2
Requesting Exceptions 3

FOR the purpose of repealing the prohibition on certain insurers, nonprofit health service 4
plans, and health maintenance organizations imposing a step therapy or fail–first 5
protocol on an insured or an enrollee under certain circumstances; repealing the 6
prohibition on certain insurers, nonprofit health service plans, and health 7
maintenance organizations imposing a step therapy or fail–first protocol on an 8
insurer or an enrollee for a certain prescription drug under certain circumstances; 9
requiring a step therapy protocol to be established by using certain criteria based on 10
certain guidelines; establishing certain requirements for certain guidelines; 11
authorizing the substitution of certain publications in the absence of certain 12
guidelines; requiring certain insurers, nonprofit health service plans, or health 13
maintenance organizations to establish a certain process for requesting an exception 14
step therapy protocol; authorizing certain entities to use an existing medical 15
exceptions process to satisfy a certain requirement; requiring that a step therapy 16
exception request be granted in a certain manner under certain circumstances; 17
requiring a certain entity to authorize coverage for a certain prescription drug under 18
certain circumstances; requiring certain entities to grant or deny certain requests 19
and appeals within a certain period of time; providing that certain requests or 20
appeals be treated as granted under certain circumstances; requiring that certain 21
requests that are denied under certain circumstances be eligible for certain appeal; 22
requiring the Maryland Insurance Commissioner to adopt certain regulations; 23
making conforming changes; defining certain terms; providing for the application of 24
this Act; providing for a delayed effective date; and generally relating to step therapy 25
protocols and health insurance. 26

BY repealing and reenacting, without amendments, 27
Article – Health – General 28
Section 19–108.2(a)(1) 29
Annotated Code of Maryland 30

2 HOUSE BILL 1359

(2019 Replacement Volume) 1

BY repealing and reenacting, with amendments, 2
Article – Health – General 3
Section 19–108.2(a)(5), (b), and (c)(4) 4
Annotated Code of Maryland 5
(2019 Replacement Volume) 6

BY repealing 7
Article – Insurance 8
Section 15–142 9
Annotated Code of Maryland 10
(2017 Replacement Volume and 2019 Supplement) 11

BY adding to 12
Article – Insurance 13
Section 15–142 14
Annotated Code of Maryland 15
(2017 Replacement Volume and 2019 Supplement) 16

SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, 17
That the Laws of Maryland read as follows: 18

Article – Health – General 19

19–108.2. 20

(a) (1) In this section the following words have the meanings indicated. 21

(5) “Step therapy [or fail–first] protocol” has the meaning stated in § 22
15–142 of the Insurance Article. 23

(b) In addition to the duties stated elsewhere in this subtitle, the Commission 24
shall work with payors and providers to attain benchmarks for: 25

(1) Standardizing and automating the process required by payors for 26
preauthorizing health care services; and 27

(2) Overriding a payor’s step therapy [or fail–first] protocol. 28

(c) The benchmarks described in subsection (b) of this section shall include: 29

(4) On or before July 1, 2015, establishment, by each payor that requires a 30
step therapy [or fail–first] protocol, of a process for a provider to override the step therapy 31
[or fail–first] protocol of the payor; and 32

Article – Insurance 33

HOUSE BILL 1359 3

[15–142. 1

(a) (1) In this section the following words have the meanings indicated. 2

(2) “Step therapy drug” means a prescription drug or sequence of 3
prescription drugs required to be used under a step therapy or fail–first protocol. 4

(3) “Step therapy or fail–first protocol” means a protocol established by an 5
insurer, a nonprofit health service plan, or a health maintenance organization that requires 6
a prescription drug or sequence of prescription drugs to be used by an insured or an enrollee 7
before a prescription drug ordered by a prescriber for the insured or the enrollee is covered. 8

(4) “Supporting medical information” means: 9

(i) a paid claim from an entity subject to this section for an insured 10
or an enrollee; 11

(ii) a pharmacy record that documents that a prescription has been 12
filled and delivered to an insured or an enrollee, or a representative of an insured or an 13
enrollee; or 14

(iii) other informati