No CRS summary available for this bill.
This section requires group health plans and health insurance issuers offering group coverage that use medication step therapy protocols (i.e., requiring patients to try lower-cost or preferred prescription drugs before others) to implement a clear, prompt, and transparent process for participants, beneficiaries, or prescribers to request exceptions. Exceptions must be approved, with coverage of the requested drug at the plan year's initial cost-sharing rates, if any of the following apply: (1) prior required treatments were ineffective; (2) delay risks severe or irreversible consequences; (3) required treatments are contraindicated or likely to cause harm; (4) required treatments impair occupational or daily living functions; (5) the patient is stable on the drug after prior plan approval; or (6) other circumstances determined by the Secretary. The process must allow clinical rationales and medical information; use a standard form available in paper and electronic formats; limit required documentation; outline expedited review conditions; permit representatives to assist; and disclose details in plan materials including summaries of benefits.