IC 27-1-37.4-8: "Step therapy protocol"; notice of denial; required information

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:

(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.