Nevada Revised Statutes 695C.17095 – Plan covering prescription drug for treatment of medical condition that is part of step therapy protocol: Use of certain guidelines required; establishment of process to request exemption from step therapy protoco…
1. When developing a step therapy protocol, a health maintenance organization shall use guidelines based on medical or scientific evidence, if such guidelines are available.
Terms Used In Nevada Revised Statutes 695C.17095
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Enrollee: means a natural person who has been voluntarily enrolled in a health care plan. See Nevada Revised Statutes 695C.030
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Health care plan: means any arrangement whereby any person undertakes to provide, arrange for, pay for or reimburse any part of the cost of any health care services and at least part of the arrangement consists of arranging for or the provision of health care services paid for by or on behalf of the enrollee on a periodic prepaid basis. See Nevada Revised Statutes 695C.030
- Health maintenance organization: means any person which provides or arranges for provision of a health care service or services and is responsible for the availability and accessibility of such service or services to its enrollees, which services are paid for or on behalf of the enrollees on a periodic prepaid basis without regard to the dates health services are rendered and without regard to the extent of services actually furnished to the enrollees, except that supplementing the fixed prepayments by nominal additional payments for services in accordance with regulations adopted by the Commissioner shall not be deemed to render the arrangement not to be on a prepaid basis. See Nevada Revised Statutes 695C.030
2. A health maintenance organization that offers or issues a health care plan which includes coverage for a prescription drug for the treatment of any medical condition that is part of a step therapy protocol shall:
(a) Establish a clear, convenient and readily accessible process by which an enrollee and his or her attending practitioner may:
(1) Request an exemption for the enrollee from the step therapy protocol; and
(2) Appeal a decision made by the health maintenance organization concerning a request for an exemption from the step therapy protocol pursuant to subparagraph (1);
(b) Make the process described in paragraph (a) accessible through an Internet website maintained by the health maintenance organization; and
(c) Except as otherwise provided in this paragraph, respond to a request made or an appeal submitted pursuant to paragraph (a) not later than 2 business days after the request is made or the appeal is submitted, as applicable. If the attending practitioner indicates that exigent circumstances exist, the health maintenance organization shall respond to the request or appeal within 24 hours after the request is made or the appeal is submitted, as applicable.
3. A health maintenance organization shall grant a request to exempt an enrollee from a step therapy protocol made in accordance with the process established pursuant to subsection 2 if the attending practitioner for the enrollee submits to the health maintenance organization a statement which provides an adequate justification for the exemption and any documentation necessary to support the statement. The health maintenance organization shall determine whether such justification exists if the statement and documentation demonstrate that:
(a) Each prescription drug that is required to be used earlier in the step therapy protocol:
(1) Is contraindicated or will likely cause an adverse reaction or physical or mental harm to the enrollee;
(2) Is expected to be ineffective based on the known clinical characteristics of the enrollee and the known characteristics of the required prescription drug;
(3) Has been tried by the enrollee, regardless of whether the enrollee was covered by the current health care plan at the time, and was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event relating to the prescription drug; or
(4) Is not in the best interest of the enrollee, based on medical necessity; or
(b) The enrollee is stable on a prescription drug selected by his or her attending practitioner for the medical condition under consideration, regardless of whether the enrollee was covered by his or her current health care plan at the time the attending practitioner selected the drug.
4. If a health maintenance organization does not respond to a request for an exemption from a step therapy protocol or an appeal concerning a decision relating to such a request within the time frame prescribed by paragraph (c) of subsection 2, the request shall be deemed to have been granted.
5. If a request for an exemption from a step therapy protocol is granted pursuant to subsection 3 or deemed granted pursuant to subsection 4, the health maintenance organization shall immediately authorize coverage for and dispensing of the drug chosen by the attending practitioner for the enrollee.
6. A health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2024, has the legal effect of including the coverage required by this section, and any provisions of the policy that conflict with the provisions of this section is void.
7. The provisions of this section do not apply to any prescription drug to which the provisions of NRS 695C.17333 apply.
8. As used in this section:
(a) ’Attending practitioner’ means the practitioner, as defined in NRS 639.0125, who has primary responsibility for the treatment of the medical condition of an insured for which a prescription drug is prescribed.
(b) ’Medical or scientific evidence’ has the meaning ascribed to it in NRS 695G.053.