20-3651. Definitions In this article, unless the context otherwise requires: 1. " Clinical practice guidelines" means a systematically developed statement to assist health care providers and patients in making decisions about appropriate health care for specific clinical circumstances and conditions. 2. " Clinical review criteria" means the written screening procedures, decision abstracts, clinical protocols and […]
20-3652. Applicability This article applies to: 1. Any health care plan that is subject to state law regulating insurance, that provides prescription drug benefits and that includes coverage for a step therapy protocol regardless of how that coverage is described. 2. A contractor, agent or similar entity that implements coverage for a step therapy protocol […]
20-3653. Clinical review criteria A. Clinical review criteria that are used by a health care insurer, pharmacy benefit manager or utilization review agent to establish a step therapy protocol shall be based on clinical practice guidelines that: 1. Recommend that the prescription drugs be taken in the specific sequence required by the step therapy protocol. […]
20-3654. Exceptions; process A. Notwithstanding any other law, if coverage of a prescription drug for the treatment of any medical condition is restricted for use by a health care insurer, pharmacy benefit manager or utilization review agent through the use of a step therapy protocol, the patient and prescribing provider shall have access to a […]
