Bill Summary – FastDemocracy

LB1148                                                                              LB1148
                                                                                2024
                                  LEGISLATURE OF NEBRASKA
                            ONE HUNDRED EIGHTH LEGISLATURE
                                      SECOND SESSION
                        LEGISLATIVE BILL 1148
      Introduced by Hansen, 16.
      Read first time January 11, 2024
      Committee: Banking, Commerce and Insurance
 A BILL FOR AN ACT relating to insurance; to amend section 44-7,115,
         Reissue Revised Statutes of    Nebraska;   to change requirements
        relating to step-therapy as prescribed; and to repeal the original
        section.
    Be it enacted by the people of the State of Nebraska,
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           Section 1. Section 44-7,115, Reissue Revised Statutes of Nebraska,
  is amended to read:
          44-7,115 (1) A step-therapy override exception shall be approved by
     a health carrier or   utilization review organization if   any of   the
  following circumstances apply:
          (a) The prescription drug required under the step-therapy protocol
     is contraindicated pursuant to    the drug manufacturer's prescribing
 information for the drug or, due to a documented adverse event with a
    previous use or a documented medical condition, including a comorbid
     condition, is likely to do any of the following:
           (i) Cause an adverse reaction to the covered individual;
          (ii) Decrease the ability of the covered individual to achieve or
    maintain reasonable functional ability in performing daily activities; or
          (iii) Cause physical or mental harm to the covered individual;
           (b) The prescription drug required under the step-therapy protocol
  is expected to be ineffective based on the known clinical characteristics
    of the covered person, such as the covered person's adherence to or
    compliance with the covered person's individual plan of care, and any of
    the following:
           (i) The known characteristics of the prescription drug regimen as
  described in     peer-reviewed literature or   in the manufacturer's
  prescribing information for the drug;
          (ii) The health care provider's medical judgment based on clinical
    practice guidelines or peer-reviewed journals; or
           (iii)     The covered person's documented experience with the
     prescription drug regimen;
           (c)     The covered person has had     a trial of    a therapeutically
  equivalent dose of the prescription drug under the step-therapy protocol
  while under the covered person's current or previous health benefit plan
  for a period of time to allow for a positive treatment outcome, and such
 prescription drug was discontinued by the covered person's health care
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LB1148                                                                                               LB1148
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  provider due to lack of effectiveness; or
        (d) The covered person is currently receiving a positive therapeutic
     outcome on a prescription drug selected by the covered person's health
  care provider for the medical condition under consideration while under
  the covered person's current or previous health benefit plan. Nothing in
 the Step-Therapy Reform Act shall prohibit the distribution of   a
    pharmaceutical sample, except that the pharmaceutical sample may not be
    used to meet the requirements of this subdivision.
         (2) Upon the approval of a step-therapy override exception, the
  health carrier or   utilization review organization shall authorize
  coverage for the prescription drug selected by    the covered person's
     prescribing health care provider if the prescription drug is a covered
  prescription drug under the covered person's health benefit plan.
         (3) Except in the case of an urgent care request, a health carrier
  or utilization review organization shall make a determination to approve
  or deny a request for a step-therapy override exception within five
     calendar days after receipt of complete, clinically relevant written
  documentation supporting    a step-therapy override exception under
  subsection (1) of this section. In the case of an urgent care request, a
  health carrier or utilization review organization shall approve or deny a
     request for a step-therapy override exception within seventy-two hours
  after receipt of such documentation. If a request for a step-therapy
  override exception is    incomplete or     additional clinically relevant
  information is    required,    the health carrier or    utilization review
  organization may request such information within the applicable time
  period provided in this section. Once the information is submitted, the
  applicable time period for approval or denial shall begin again. If a
  health carrier or utilization review organization fails to respond to the
  request for a step-therapy override exception within the applicable time,
  the step-therapy override exception shall be deemed granted.
         (4) If a request for a step-therapy override exception is denied,
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LB1148                                                                                    LB1148
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    the health carrier or utilization review organization shall provide the
    covered person or the covered person's authorized representative and the
    covered person's prescribing health care provider with the reason for the
    denial and information regarding the procedure to request external review
    of the denial pursuant to the Health Carrier External Review Act. Any
    denial of a request for a step-therapy override exception that is upheld
    on an internal appeal shall be considered a final adverse determination
    for purposes of the Health Carrier External Review Act and is eligible
     for a request for external review by a covered person or the covered
 person's authorized representative pursuant to   the Health Carrier
    External Review Act.
        (5) This section shall not be construed to prevent:
         (a)   A   health carrier or    utilization review organization from
    requiring a pharmacist to effect substitutions of prescription drugs
    consistent with section 28-414.01, 38-28,111, or 71-2478;
        (b) A health care provider from prescribing a prescription drug that
    is determined to be medically appropriate; or
        (c)   A   health carrier or    utilization review organization from
    requiring a covered person to try a prescription drug with the same
     generic name and demonstrated bioavailability,      a biosimilar,    or   a
    biological product that is an interchangeable biological product pursuant
     to the Nebraska Drug Product Selection Act prior to providing coverage
     for the equivalent branded prescription drug.
        (6) For purposes of this section, biosimilar has the same meaning as
    defined in 42 U.S.C. 262(i)(2) or interchangeable biological product as
    defined in 42 U.S.C. 262(i)(3).
         Sec. 2.      Original section 44-7,115, Reissue Revised Statutes of
  Nebraska, is repealed.
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