Ark. Code Ann. § 23-99-1114: Limitation on step therapy - Definitions

(a) An insurance policy shall not limit or exclude coverage under the health benefit plan for a drug approved by the United States Food and Drug Administration that is on the prescription drug formulary of the insurance policy by mandating that a covered person undergo step therapy if the insurance policy provides coverage for the treatment of: (1) Psychosis and serious mental illness through antipsychotic prescription drugs; and (2) Metastatic cancer unless the preferred drug is consistent with best practices that: (A) Are used for the treatment of metastatic cancer or associated conditions under: (i) United States Food and Drug Administration-approved indication; or (ii) The National Comprehensive Cancer Network Drugs and Biologics Compendium indication; or (B) Use evidence-based, peer-reviewed, recognized medical literature. (b) As used in this section: (1) "Metastatic cancer" means cancer that has spread from a primary or original site of the cancer to surrounding or nearby tissues, lymph nodes, or other parts of the body; (2) (A) "Psychosis" means a condition that affects the mind and affects the way the brain processes information. (B) "Psychosis" includes delusions and hallucinations; and (3) "Serious mental illness" means a mental, behavioral, or emotional disorder resulting in serious functional impairment, that substantially interferes with or limits one (1) or more major life activities. (c) For psychosis and serious mental illness, if there is a generic drug equivalent approved by the United States Food and Drug Administration under the same chemical or generic name of a name brand drug that is available, it is not considered step therapy to allow access to and coverage for both the generic drug and the name brand drug. (d) If a request for prior authorization is denied due to a step therapy requirement under this section, then the utilization review entity shall authorize the preferred treatment required under the step therapy if a prior authorization for the preferred treatment is required without requiring the healthcare provider to submit a new or revised request. Amended by Act 2023, No. 577,§ 1, eff. 8/1/2023. Amended by Act 2023, No. 501,§ 4, eff. 8/1/2023. Amended by Act 2021, No. 97,§ 5, eff. 7/28/2021. Amended by Act 2019, No. 699,§ 5, eff. 7/24/2019. Amended by Act 2019, No. 699,§ 4, eff. 7/24/2019. Amended by Act 2017, No. 815,§ 11, eff. 8/1/2017. Added by Act 2015, No. 1106,§ 2, eff. 7/22/2015.

(a) An insurance policy shall not limit or exclude coverage under the health benefit plan for a drug approved by the United States Food and Drug Administration that is on the prescription drug formulary of the insurance policy by mandating that a covered person undergo step therapy if the insurance policy provides coverage for the treatment of: (1) Psychosis and serious mental illness through antipsychotic prescription drugs; and (2) Metastatic cancer unless the preferred drug is consistent with best practices that: (A) Are used for the treatment of metastatic cancer or associated conditions under: (i) United States Food and Drug Administration-approved indication; or (ii) The National Comprehensive Cancer Network Drugs and Biologics Compendium indication; or (B) Use evidence-based, peer-reviewed, recognized medical literature.

(1) Psychosis and serious mental illness through antipsychotic prescription drugs; and

re used for the treatment of metastatic cancer or associated conditions under: (i) United States Food and Drug Administration-approved indication; or (ii) The National Comprehensive Cancer Network Drugs and Biologics Compendium indication; or (B) Use evidence-based, peer-reviewed, recognized medical literature.

(1) Psychosis and serious mental illness through antipsychotic prescription drugs; and

(2) Metastatic cancer unless the preferred drug is consistent with best practices that: (A) Are used for the treatment of metastatic cancer or associated conditions under: (i) United States Food and Drug Administration-approved indication; or (ii) The National Comprehensive Cancer Network Drugs and Biologics Compendium indication; or (B) Use evidence-based, peer-reviewed, recognized medical literature.

(A) Are used for the treatment of metastatic cancer or associated conditions under: (i) United States Food and Drug Administration-approved indication; or (ii) The National Comprehensive Cancer Network Drugs and Biologics Compendium indication; or

(i) United States Food and Drug Administration-approved indication; or

(ii) The National Comprehensive Cancer Network Drugs and Biologics Compendium indication; or

(B) Use evidence-based, peer-reviewed, recognized medical literature.

(b) As used in this section: (1) "Metastatic cancer" means cancer that has spread from a primary or original site of the cancer to surrounding or nearby tissues, lymph nodes, or other parts of the body; (2) (A) "Psychosis" means a condition that affects the mind and affects the way the brain processes information. (B) "Psychosis" includes delusions and hallucinations; and (3) "Serious mental illness" means a mental, behavioral, or emotional disorder resulting in serious functional impairment, that substantially interferes with or limits one (1) or more major life activities.

(1) "Metastatic cancer" means cancer that has spread from a primary or original site of the cancer to surrounding or nearby tissues, lymph nodes, or other parts of the body;

(2) (A) "Psychosis" means a condition that affects the mind and affects the way the brain processes information. (B) "Psychosis" includes delusions and hallucinations; and

(A) "Psychosis" means a condition that affects the mind and affects the way the brain processes information.

(B) "Psychosis" includes delusions and hallucinations; and

(3) "Serious mental illness" means a mental, behavioral, or emotional disorder resulting in serious functional impairment, that substantially interferes with or limits one (1) or more major life activities.

(c) For psychosis and serious mental illness, if there is a generic drug equivalent approved by the United States Food and Drug Administration under the same chemical or generic name of a name brand drug that is available, it is not considered step therapy to allow access to and coverage for both the generic drug and the name brand drug.

(d) If a request for prior authorization is denied due to a step therapy requirement under this section, then the utilization review entity shall authorize the preferred treatment required under the step therapy if a prior authorization for the preferred treatment is required without requiring the healthcare provider to submit a new or revised request.