An Act Concerning Step Therapy Requirements For Prescription Drugs Covered Under The Medicaid Program And Required Notice To Enrollees Of Prescription Drug Payment Suspensions, Denials Or Imposition Of New Requirements.
Summary
SB 331 revises Medicaid step therapy rules for prescription drugs and adds notice requirements for HUSKY Health enrollees when prescription drug payments are denied, suspended, or subject to new utilization controls. Under the bill, step therapy for Medicaid-covered drugs may follow manufacturer and FDA evidence-based guidelines; if no such guidelines exist, the step therapy period cannot exceed 30 days, after which the prescribing practitioner may determine the treatment is clinically ineffective and the prescribed drug must be covered and dispensed.
The bill also requires the Department of Social Services, or its pharmacy benefit contractor, to provide individualized notice to affected enrollees when an electronic pharmacy claim is denied, when payment for a prescribed drug is planned to be suspended or terminated, or when new prior authorization or step therapy requirements are being imposed. These notices must be timely, written in plain language, and include information about how to comply and how to pursue alternative medications, as well as any applicable appeal or due process rights under state and federal law.
Impact
The bill amends Connecticut General Statutes section 17b-274f(b) and creates a new notice requirement applicable to Medicaid/HUSKY Health prescription drug administration. It limits the duration of step therapy in cases where no evidence-based manufacturer or FDA guideline exists, and it requires coverage of the prescribed drug once the practitioner deems prior treatment clinically ineffective. It also imposes new administrative duties on DSS and any pharmacy benefit manager or contractor serving the Medicaid program to send prompt, individualized notices to enrollees about denials, suspensions, and new pharmacy utilization requirements.
Sentiment
The available voting history shows strong bipartisan or at least unanimous support in committee and the Appropriations Committee, with 23-0 and 51-0 votes respectively. No committee transcript is available, but the unanimous votes suggest the bill was generally viewed favorably as a consumer-protection and access-to-care measure for Medicaid enrollees. The bill’s focus on clearer notice and limiting prolonged step therapy appears to have broad support.
Contention
There is little visible contention in the available record, but the main policy tension is between improving patient access and preserving utilization-management tools for Medicaid pharmacy benefits. Supporters are likely to favor the bill’s limits on step therapy duration and stronger notice rights for enrollees, while any potential critics would be concerned about reduced flexibility for the Department of Social Services or managed care/pharmacy benefit administrators to control drug costs and require prior authorization. The bill text itself reflects that balance by allowing step therapy when supported by evidence-based guidelines, while setting a firm 30-day cap when such guidelines are absent.
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