Section 376.2030. Definitions

As used in sections 376.2030 to 376.2036, the following terms mean:

(1) “Health benefit plan”, the same meaning as such term is defined in section 376.1350;

(2) “Health care provider”, the same meaning as such term is defined in section 376.1350;

(3) “Health carrier”, the same meaning as such term is defined in section 376.1350;

(4) “Step therapy override exception determination”, a determination as to whether a step therapy protocol should apply in a particular situation, or whether the step therapy protocol should be overridden in favor of immediate coverage of the health care provider’s preferred prescription drug. This determination is based on a review of the patient’s health care provider’s request for an override, along with supporting rationale and documentation;

(5) “Step therapy override exception request”, a written request from the patient’s health care provider for the step therapy protocol to be overridden in favor of immediate coverage of the health care provider’s preferred prescription drug. The manner and form of the written request shall be disclosed to the patient and the health care provider as described in subsection 1 of section 376.2034;

(6) “Step therapy protocol”, a protocol or program that establishes the specific sequence in which prescription drugs for a specified medical condition and medically appropriate for a particular patient are to be prescribed and covered by a health carrier or health benefit plan;

(7) “Utilization review organization”, an entity that conducts utilization review other than an insurer or health carrier performing utilization review for its own health benefit plans.

See https://revisor.mo.gov/main/OneSection.aspx?section=376.2030&bid=33248&hl=

Section 376.2034. Restriction on step therapy protocol, patient to have access to override exception determination — procedure

If coverage of a prescription drug for the treatment of any medical condition is restricted for use by a health carrier, health benefit plan, or utilization review organization via a step therapy protocol, a patient, through his or her health care provider, shall have access to a clear, convenient, and readily accessible process to request a step therapy override exception determination.  A health carrier, health benefit plan, or utilization review organization may use its existing medical exceptions process to satisfy this requirement.  The process shall be disclosed to the patient and health care provider, which shall include the necessary documentation needed to process such request and be made available on the health carrier plan or health benefit plan website.

2.  A step therapy override exception determination shall be granted if the patient has tried the step therapy required prescription drugs while under his or her current or previous health insurance or health benefit plan, and such prescription drugs were discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event.  Pharmacy drug samples shall not be considered trial and failure of a preferred prescription drug in lieu of trying the step therapy required prescription drug.

3.  The health carrier, health benefit plan, or utilization review organization may request relevant documentation from the patient or provider to support the override exception request.

4.  Upon the granting of a step therapy override exception request, the health carrier, health benefit plan, or utilization review organization shall authorize dispensation of and coverage for the prescription drug prescribed by the patient’s treating health care provider, provided such drug is a covered drug under such policy or contract.

5.  This section shall not be construed to prevent:

(1)  A health carrier, health benefit plan, or utilization review organization from requiring a patient to try a generic equivalent or other brand name drug prior to providing coverage for the requested prescription drug; or

(2)  A health care provider from prescribing a prescription drug he or she determines is medically appropriate.

See https://revisor.mo.gov/main/OneSection.aspx?section=376.2034&bid=33249&hl=