The bill amends the Prior Authorization Act to expand the categories of drugs that are exempt from prior authorization and step therapy protocols. Specifically, it prohibits health insurers from requiring prior authorization for medications approved by the FDA that are prescribed for the treatment of autoimmune disorders, cancer, rare diseases, or substance use disorders, provided that a medical necessity determination is made by a qualified healthcare professional. Additionally, the bill stipulates that medical necessity determinations must be automatically approved within specified timeframes, ensuring timely access to necessary medications.

Furthermore, the bill establishes that health insurers cannot impose step therapy requirements for these medications unless a biosimilar, interchangeable biologic, or generic version is available. It also includes provisions for off-label medications prescribed for rare diseases, ensuring that these too are exempt from step therapy requirements under similar conditions. The changes will apply to individual or group policies issued by health insurers on or after July 1, 2025, thereby enhancing access to critical treatments for patients with specific medical conditions.

Statutes affected:
introduced version: 59A-22B-2, 59A-22B-5, 59A-22B-8
Final Version: 59A-22B-2, 59A-22B-5, 59A-22B-8