Sec. 8. (a) As used in this section, “step therapy protocol” means a protocol that specifies, as a condition of coverage under a health plan, the order in which certain prescription drugs must be used to treat a covered individual‘s condition.

     (b) A health plan that denies prior authorization for a prescription drug described in subdivision (1) or (2) shall provide, in the notice of denial, an alternative list of prescription drugs or alternative treatments as follows:

Terms Used In Indiana Code 27-1-37.4-8

  • covered individual: means an individual who is entitled to coverage under a health plan. See Indiana Code 27-1-37.4-1
  • health plan: means any of the following that provides coverage for prescription drugs:

    Indiana Code 27-1-37.4-2

  • prior authorization: includes a health plan requirement that a prescription drug be authorized for payment by the health plan before the prescription drug is provided to a particular covered individual. See Indiana Code 27-1-37.4-3
(1) If:

(A) the prescription drug is not included in the health plan’s formulary; and

(B) there is at least one (1) alternative prescription drug in the same therapeutic classification (as defined in IC 12-15-35-17.5);

the alternative list must specify the alternative prescription drugs described in clause (B) that are covered by the health plan.

(2) If the prescription drug is prescribed to treat a condition for which coverage under the health plan requires use of a step therapy protocol, the alternative list must specify the alternative prescription drugs or alternative treatments that are required by the step therapy protocol.

As added by P.L.246-2019, SEC.23 and P.L.264-2019, SEC.12.

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