7 LONG TITLE
8 General Description:
9 This bill amends health insurance provisions in the Insurance Code.
10 Highlighted Provisions:
11 This bill:
12 ▸ creates definitions;
13 ▸ prohibits the use of step therapy for pharmaceuticals unless certain conditions are
15 ▸ requires a health insurer to authorize bypass of a step drug when certain conditions
16 are met; and
17 ▸ addresses adverse benefit determinations.
18 Money Appropriated in this Bill:
20 Other Special Clauses:
22 Utah Code Sections Affected:
24 31a-22-645, Utah Code Annotated 1953
26 Be it enacted by the Legislature of the state of Utah:
27 Section 1. Section 31a-22-645 is enacted to read:
28 31a-22-645. Step therapy.
29 (1) As used in this section:
30 (a) "AB-rated generic equivalent of a drug" means a drug that is therapeutically
31 equivalent to another drug, as set forth in the latest edition of, or supplement to, the federal
32 Food and Drug Administration's Approved Drug Products with Therapeutic Equivalence
34 (b) "Drug" means the same as that term is defined in Section 58-17b-102.
35 (c) "Health care provider" means a health care provider, as defined in Section
36 78B-3-403, with authority to prescribe a step drug.
37 (d) "Health insurer" means an insurer, as defined in Subsection 31A-22-634(1).
38 (e) "Hospice" means the same as that term is defined in Section 26-21-2.
39 (f) "Medically necessary" means appropriate, under the applicable standard of care:
40 (i) to preserve or improve health, life, or function;
41 (ii) to slow the deterioration of health, life, or function; or
42 (iii) for the early screening, prevention, evaluation, diagnosis, or treatment of a disease,
43 condition, illness, or injury.
44 (g) "Step drug" means a drug described in Subsection (1)(h) that must be used before
45 an insured's health benefit plan will pay for a drug ordered by the insured's health care provider.
46 (h) "Step therapy" means a fail-first protocol that requires an insured to use a drug, or
47 several drugs in a particular order, before the insured's health benefit plan will pay for a drug
48 ordered by the insured's health care provider.
49 (2) A health insurer may not offer a health benefit plan that includes step therapy
50 unless the health insurer:
51 (a) notifies each insured covered by the plan of the process described in Subsections
52 (3) through (7) for bypassing use of a step drug; and
53 (b) makes available on the health insurer's website forms for an insured to make a
54 request to bypass use of a step drug.
55 (3) Except as provided in Subsection (5)(a), a health insurer shall authorize an insured
56 to bypass use of one or more step drugs if, for each step drug to be bypassed, the insured
57 submits to the health insurer information documenting to the satisfaction of the health insurer
58 that one or more of the following conditions have been satisfied:
59 (a) the step drug:
60 (i) is contraindicated;
61 (ii) will likely cause an adverse reaction by the insured;
62 (iii) will likely cause physical or mental harm to the insured;
63 (iv) is expected to be ineffective, based on the known clinical characteristics of the
64 insured and the known clinical characteristics of the step drug regimen;
65 (v) is not medically necessary; or
66 (vi) was used by the insured previously while the insured was covered by the health
67 benefit plan, another health benefit plan, or no health benefit plan, and the use was
68 discontinued due to an adverse event or a lack of efficacy, including diminished efficacy; or
69 (b) another drug belonging to the same class of drugs and having the same mechanism
70 of action was used by the insured previously while the insured was covered by the health
71 benefit plan, another health benefit plan, or no health benefit plan, and the use was
72 discontinued due to an adverse event or a lack of efficacy, including diminished efficacy.
73 (4) Except as provided in Subsection (5)(a), a health insurer shall authorize an insured
74 to bypass use of all step drugs if the insured submits to the health insurer information
75 documenting that the insured has been admitted to hospice.
76 (5) (a) A health insurer is not required to authorize bypass of a step drug under
77 Subsection (3) or (4) if the step drug is an AB-rated generic equivalent of a drug that would be
78 covered by the health benefit plan if the bypass were authorized.
79 (b) An authorization to bypass use of one or more step drugs is not an authorization for
80 coverage of a drug that is not otherwise covered by the health benefit plan.
81 (6) Within three business days of receipt of an insured's request to bypass use of a step
82 drug, including receipt of all information necessary for the health insurer to determine whether
83 at least one of the conditions under Subsection (3) has been satisfied or the insured has been
84 admitted to hospice, the health insurer shall notify the insured of whether the request has been
86 (7) If an insured disagrees with a health insurer's determination made under Subsection
87 (3) or (4), the insured may, in accordance with Section 31A-22-629, submit an adverse benefit
89 (a) to the insurer; or
90 (b) for independent review.
91 (8) This section may not be construed to limit a health care provider's authority to
92 prescribe drugs.
93 (9) This section applies to a health benefit plan renewed or entered into on or after
94 January 1, 2018.