Prior authorization for prescription drugs or step

therapy for certain conditions prohibited. A. Coverage for medication approved by the federal food and drug administration that is prescribed for the treatment of an autoimmune disorder, cancer, a rare disease or condition, a serious mental illness or a substance use disorder, pursuant to a medical necessity determination made by a health care professional from the same or similar practice specialty that typically manages the medical condition, procedure or treatment under review, shall not be subject to prior authorization, except in cases in which a biosimilar, interchangeable biologic or generic version is available. Medical necessity determinations shall be automatically approved within three business days for standard determinations and twenty-four hours for emergency determinations when a delay in treatment could: (1) seriously jeopardize a covered person's life or overall health; (2) affect a covered person's ability to regain maximum function; or (3) subject a covered person to severe and intolerable pain. B. A health insurer or pharmacy benefits manager shall not impose step therapy requirements before authorizing coverage for medication approved by the federal food and drug administration that is prescribed for the treatment of an autoimmune disorder, cancer, a serious mental illness or a substance use disorder, pursuant to a medical necessity determination made by a health care professional from the same or similar practice specialty that typically manages the medical condition, procedure or treatment under review, except in cases in which a biosimilar, interchangeable biologic or generic version is available. Prior authorization or step therapy requirements may be used when necessary for the clinical safety of a person with a serious mental illness if the person is: (1) younger than eighteen years of age; or (2) residing in an institutionalized setting. C. A health insurer or pharmacy benefits manager shall not impose step therapy requirements before authorizing coverage for an off-label medication that is prescribed for the treatment of a rare disease or condition, pursuant to a medical necessity determination made by a health care professional from the same or similar practice specialty that typically manages the medical condition, procedure or treatment under review, except in cases in which a biosimilar, interchangeable biologic or generic version is available. Medical necessity determinations shall be automatically approved within three business days for standard determinations and twenty-four hours for emergency determinations when a delay in treatment could: (1) seriously jeopardize a covered person's life or overall health; (2) affect a covered person's ability to regain maximum function; or (3) subject a covered person to severe and intolerable pain. D. After a health insurer or pharmacy benefits manager approves prior authorization for a chronic maintenance drug, the health insurer or pharmacy benefits manager shall not require subsequent prior authorization more than once every three years, unless: (1) the prior authorization was obtained based on fraud or misrepresentation; (2) final action by the federal food and drug administration, other regulatory agencies or the drug manufacturer: (a) removes the chronic maintenance drug from the market; (b) limits use of the chronic maintenance drug in a manner that affects the prior authorization; or (c) communicates a patient safety issue that would affect the prior authorization; (3) a generic equivalent or drug that is biosimilar to the chronic maintenance drug is added to the health insurer's or pharmacy benefits manager's drug formulary; or (4) the prescription is written for drugs that may have a cosmetic use, including weight loss medications. History: Laws 2023, ch. 114, § 13; 2024, ch. 42, § 4; 2025, ch. 57, § 3; 2026, ch. 47, § 4.