An Act To Provide Protections for Maine Patients Facing Step Therapy
Sec. 1. 24-A MRSA §4320-M is enacted to read:
§ 4320-M. Step therapy
(1) The required prescription drug is contraindicated or will likely cause an adverse reaction in or physical or mental harm to the enrollee;
(2) The required prescription drug is expected to be ineffective based on the known clinical characteristics of the enrollee and the known characteristics of the prescription drug regimen;
(3) The enrollee has tried the required prescription drug while under the enrollee's current or previous health insurance or health plan, or another prescription drug in the same pharmacologic class or with the same mechanism of action, and the prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse reaction;
(4) The required prescription drug is not in the best interest of the enrollee, based on medical necessity; or
(5) The enrollee is stable on a prescription drug selected by the enrollee's health care provider for the medical condition under consideration while on a current or previous health insurance or health plan.
Nothing in this paragraph may be construed to encourage the use of a pharmaceutical sample for the sole purpose of meeting the requirements for the granting of a step therapy override exception determination.
(1) A carrier or utilization review organization from requiring an enrollee to try a generic drug, as defined in Title 32, section 13702-A, subsection 14, or an interchangeable biological product, as defined in Title 32, section 13702-A, subsection 14-A, prior to providing coverage for the equivalent brand-name prescription drug; or
(2) A health care provider from prescribing a prescription drug that is determined to be medically necessary.
Sec. 2. Application. The requirements of this Act apply to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after January 1, 2020. For purposes of this Act, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date.