PBMs serve as the “middlemen” between drug manufacturers and insurance companies. They control the list of drugs your insurance company covers each year.
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Great news – Arizona has passed restrictions on copay accumulators.
The law (§20-1126) requires insurers to count any payment made by the patient or on behalf of the patient when calculating a patient’s contribution to any out-of-pocket maximum, deductible, copayment, coinsurance or any cost-sharing requirement. However, the drug must be either:
A “generic equivalent” means a drug that has an identical amount of the same active chemical ingredients in the same dosage form. It must meet applicable standards of strength or other nationally recognized collection. It does not include a drug that is listed by the FDA as having unresolved bioequivalence.
If a patient has obtained access to the drug through prior authorization, a step therapy protocol, or an exceptions and appeals process; the patient’s copay assistance must be counted by their insurer.
If you believe an insurance company has failed to comply with §20-1126, you can file a complaint with Arizona’s Department of Insurance.
Montana has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Montana’s Department of Insurance.
Nebraska has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Nebraska’s Department of Insurance
Nevada has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above laws, you can file a complaint with Nevada’s Department of Insurance.
New Hampshire has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with New Hampshire’s Department of Insurance.
New Jersey has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with New Jersey’s Department of Insurance.
New Mexico has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with New Mexico’s Department of Insurance.
New York has enacted laws regulating PBMs:
– PBMs are required to be licensed in the state (N.Y. Ins. Law § 2903)
– PBMs are required to have a fiduciary duty towards health plans and their enrollees (N.Y. Pub. Health Law § 280-A(2))
– PBMs are required to submit data to the state of New York and the health plans with which they contract (N.Y. Ins. Law § 2904)
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with New York’s Department of Insurance.
North Dakota has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with North Dakota’s Department of Insurance.
North Carolina has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with North Carolina’s Department of Insurance.
Ohio has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Ohio’s Department of Insurance.
Oklahoma has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Oklahoma’s Department of Insurance.
Oregon has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Oregon’s Department of Insurance.
Pennsylvania has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Pennsylvania’s Department of Insurance.
Rhode Island has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Rhode Island’s Department of Insurance.
South Carolina has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with South Carolina’s Department of Insurance.
South Dakota has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with South Dakota’s Department of Insurance.
Tennessee has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Tennessee’s Department of Insurance.
Texas has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Texas’ Department of Insurance.
Utah has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Utah’s Department of Insurance.
West Virginia has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with West Virginia’s Department of Insurance.
Wisconsin has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Wisconsin’s Department of Insurance.
Vermont has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Vermont’s Department of Insurance.
Virginia has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Virginia’s Department of Insurance.
Washington has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Washington’s Department of Insurance.
Wyoming has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Wyoming’s Department of Insurance.
DC has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with DC’s Department of Insurance.
Missouri has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Missouri’s Department of Insurance.
Mississippi has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Mississippi’s Department of Insurance.
Minnesota has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Minnesota’s Department of Insurance.
Michigan has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Michigan’s Department of Insurance.
Massachusetts has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Massachusetts’s Department of Insurance.
Maryland has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Maryland’s Department of Insurance.
Maine has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Maine’s Department of Insurance.
Louisiana has enacted laws regulating PBMs:
If you believe a PBM has failed to comply with the above laws, you can file a complaint with Louisiana’s Department of Insurance.
Kentucky has enacted laws regarding PBMs:
If you believe a PBM has failed to comply with the above laws, you can file a complaint with Kentucky’s Department of Insurance.
Kansas has enacted laws regarding PBMs:
If you believe a PBM has failed to comply with the above laws, you can file a complaint with Kansas’ Department of Insurance.
Iowa has enacted laws regarding PBMs:
If you believe a PBM has failed to comply with the above laws, you can file a complaint with Iowa’s Department of Insurance.
Indiana has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Indiana’s Department of Insurance.
Illinois has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Illinois’ Department of Insurance.
Hawaii has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Hawaii’s Department of Insurance.
Georgia has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Georgia’s Department of Insurance.
Florida has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Florida’s Department of Insurance.
Delaware has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Delaware’s Department of Insurance.
Connecticut has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Connecticut’s Department of Insurance.
Colorado has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Colorado’s Department of Insurance.
California has enacted laws regulating PBMs.
Arkansas has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Arkansas’ Department of Insurance.
Arizona has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Arizona’s Department of Insurance.
Alaska has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Alaska’s Department of Insurance.
Alabama has enacted laws regulating PBMs.
If you believe a PBM has failed to comply with the above statutes, you can file a complaint with Alabama’s Department of Insurance.
Great news – the District of Columbia has passed restrictions on copay accumulators.
This law (§ 48–855.02b) amends DC’s insurance laws to require insurers to include cost-sharing amounts paid by the patient or on the patient’s behalf when calculating the patient’s contribution to an applicable cost-sharing requirement, such as a copay, coinsurance, or deductible. However, this requirement does not apply to prescription drugs for which these is a generic/biosimilar alternative, unless the patient has obtained access to the brand-name drug through prior authorization, a step therapy protocol, or the insurer’s exceptions and appeals process.
If you believe an insurance company has failed to comply with § 48–855.02b, you can file a complaint with DC Department of Insurance.
Great news – West Virginia has passed restrictions on copay accumulators.
This law (§33-15-4t) establishes that when calculating a patient’s contribution to any applicable cost-sharing requirement, such as copayments, coinsurance, or deductibles, both insurers and pharmacy benefit managers (PBMs) must include any cost-sharing amounts paid by the insured or on their behalf by another person.
If you believe an insurance company has failed to comply with §33-15-4t, you can file a complaint with West Virginia Department of Insurance.
Great news – Washington has passed restrictions on copay accumulators.
This law (Chapter 228) requires health carriers and health care benefit managers to count any cost-sharing amounts paid by a patient or on their behalf by another person towards the enrollee’s applicable cost-sharing, deductible, or out-of-pocket maximum, regardless of the source of the payment. This applies to certain prescription drugs without a generic equivalent or preferred therapeutic equivalent, as well as drugs accessed through prior authorization, step therapy, or an exception request process. This bill provides exceptions for high-deductible healthplans to preserve the patient’s ability to make tax-exempt contributions and withdrawals from a health savings account.
If you believe an insurance company has failed to comply with Chapter 228, you can file a complaint with Washington Department of Insurance.
Great news – Virginia has passed restrictions on copay accumulators.
This law (§38.2-3407.20) states that when calculating a patient’s overall contribution to any out-of-pocket maximum or any cost-sharing requirement under a health paln, a carrier shall include any amounts paid by the patient or paid on beahlf of the patient by another person. However, if the application of this provision would result in a health plan’s ineligibility to qualify as a Health Savings Account-qualified High Deductible Health Plan, then the above requirement shall not apply until after the patient has satisified the minimum deductible.
If you believe an insurance company has failed to comply with §38.2-3407.20, you can file a complaint with Virginia Department of Insurance.
Great news – Vermont has passed restrictions on copay accumulators.
This law (8 V.S.A. chapter 107 § 4093) requires health benefit plan issuers or pharmacy benefit managers (PBMs) to apply any payment made by or on behalf of a patient for certain prescription drugs to the patient’s deductible, copayment, cost-sharing responsibility, or out-of-pocket maximum. However, this only applies to prescription drugs that do not have a generic equivalent or interchangeable biological product, or where the patient has obtained access to the drug through a prior authorization process, step therapy protocol, or the issuer’s exceptions and appeals process. These provisions apply to a high-deductible health plan only to the extent that it would not disqualify the plan from eligibility for a health savings account pursuant to 26 U.S.C. § 223.
Insurers also cannot require patients to pay more at the point of sale for a covered prescription drug than the least of the applicable cost-sharing amount, the maximum allowable cost for the drug, or the amount the covered person would pay for the drug (after application of any known discounts) if the covered person were paying the cash price.
If you believe an insurance company has failed to comply with 8 V.S.A. chapter 107 § 4093, you can file a complaint with Vermont’s Department of Insurance.
Great news – Texas has passed restrictions on copay accumulators.
This law (§ 1369.0542) amends the Texas Insurance Code to require health benefit plan issuers or pharmacy benefit managers (PBMs) to apply any third-party payment, financial assistance, discount, product voucher, or other reduction in out-of-pocket expenses made by or on behalf of a patient for certain prescription drugs to the patient’s deductible, copayment, cost-sharing responsibility, or out-of-pocket maximum. However, this only applies to prescription drugs that do not have a generic equivalent or interchangeable biological product, or where the patient has obtained access to the drug through a prior authorization process, step therapy protocol, or the issuer’s exceptions and appeals process.
If you believe an insurance company has failed to comply with § 1369.0542, you can file a complaint with Texas Department of Insurance.
Great news – Tennessee has passed restrictions on copay accumulators.
This law (Tennessee Code Annotated, Section 56-7-3201) amends Tennessee’s insurance laws to require insurers to include cost sharing amounts paid by the enrollee, or on behalf of the enrollee by another person, when calculating an enrollee’s contribution to an applicable cost sharing requirement.
If you believe an insurance company has failed to comply with Tennessee Code Annotated, Section 56-7-3201, you can file a complaint with the Tennessee Department of Insurance.
Great news – Oregon has passed restrictions on copay accumulators.
This law (HB 4113) requires insurers to include all amounts paid by an enrollee or paid by another person on behalf of an enrollee when calculating the enrollee’s contribution to an out-of-pocket maximum, deductible, copayment, coinsurance or other cost-sharing requirement applied to the drug if:
1) The drug does not have a generic equivalent; or
2) The drug has a generic equivalent and the enrollee has: (a) obtained prior authorization from the insurer or pharmacy benefit manager; (b) complied with a step therapy protocol; or (c) received approval from the insurer or pharmacy benefit manager through the insurer’s or the pharmacy benefit manager’s exceptions, appeal or review process.
If you believe an insurance company has failed to comply with HB 4113, you can file a complaint with Oregon’s Department of Insurance.
Great news – Oklahoma has passed restrictions on copay accumulators.
This law (36 O.S. Supp. 2020, Section 1250.5[18]) prohibits insurers and pharmacy benefit managers from failing to include any amount paid by a patient or on their behalf when calculating the patient’s total contribution to out-of-pocket maximums, deductibles, copayments, coinsurance, or other cost-sharing requirements.
If you believe an insurance company has failed to comply with 36 O.S. Supp. 2020, Section 1250.5(18), you can file a complaint with Oklahoma’s Department of Insurance.
Great news – North Dakota has passed restrictions on copay accumulators.
Starting January 1, 2026, this law (North Dakota Century Code 26.1-36) prohibits health plans from not including any amount paid by the enrollee or paid on behalf of the enrollee by another person when calculating an enrollee’s overall contribution to any out-of-pocket maximum or any cost-sharing requirement for a prescription drug under the health plan. The health benefit plan also may not vary the out-of-pocket maximum or cost-sharing requirement, or otherwise design benefits accounting for the availability of a cost-sharing assistance program for a prescription drug.
However, if the application of this provision would result in a health plan’s ineligibility to qualify as a Health Savings Account-qualified High Deductible Health Plan, then the above requirement shall not apply until after the patient has satisified the minimum deductible.
If you believe an insurance company has failed to comply with North Dakota Century Code 26.1-36, you can file a complaint with North Dakota’s Department of Insurance.
Great news – North Carolina has passed restrictions on copay accumulators.
This law (§ 58-56A-3) requires insurers and pharmacy benefit managers (PBMs) to include any amounts paid by the insured, or on the insured’s behalf, for a prescription that is either without an AB-rated generic equivalent or with an AB-rated generic equivalent if the insured has obtained authorization for the drug through prior authorization from the insurer or PBM, a step therapy protocol, or the exception or appeal process of the insurer or PMB.
If you believe an insurance company has failed to comply with § 58-56A-3, you can file a complaint with North Carolina’s Department of Insurance.
Great news – New York has passed restrictions on copay accumulators.
This law (A01741) requires any third-party payments, financial assistance, discounts, vouchers, or other price reduction instruments for out-of-pocket expenses made on behalf of a patient for the cost of prescription drugs to be applied to the patient’s deductible, copayment, coinsurance, out-of-pocket maximum, or any other cost-sharing requirement when calculating the insured’s overall contribution to any out-of-pocket maximum or cost-sharing requirement.
This law applies to individual and group health insurance plans, as well as contracts issued by medical expense indemnity, hospital service, and health service corporations that provide prescription drug coverage.
The act does have an exception for high-deductible health eligible for health savings accounts, where the requirement would apply after the patient has satisified the minimum deductible, except for preventative care services.
If you believe an insurance company has failed to comply with A01741, you can file a complaint with New York’s Department of Insurance.
Great news – New Mexico has passed restrictions on copay accumulators.
The law (SB 51) requires insurers to credit patients for the full value of any discounts or payments made by third parties when calculating the patient’s cost-sharing obligation for covered prescription drugs. The act prevents insurers from charging different cost-sharing amounts for prescription drugs or pharmacy services obtained at non-affiliated pharmacies or for administration of prescription drugs at different infusion sites, though they can communicate with patients about lower-cost options.
Insurers cannot require patients to pay more at the point of sale for a covered prescription drug than the least of the applicable cost-sharing amount, the amount the patient would pay without insurance, the total pharmacy reimbursement amount, or the value of the manufacturer’s rebate.
This law applies to state-regulated commercial plans and state public employee plans.
If you believe an insurance company has failed to comply with SB 51, you can file a complaint with New Mexcio’s Department of Insurance.
The state of Maryland has yet to pass restrictions on copay accumulators or maximizers. Contact your state legislators and ask for their support.
This law (15–118.1) requires insurers to include cost-sharing amounts paid by the patient or on the patient’s behalf (including discounts, financial assistance payments, product vouchers, or other out-of-pocket expenses) when calculating the patient’s contribution to an applicable cost-sharing requirement, such as a copay, coinsurance, deductible, or out-of-pocket max.
This applies for drugs that are covered under the patient’s health plan and either
However, if the application of this provision would result in a health plan’s ineligibility to qualify as a Health Savings Account-qualified High Deductible Health Plan, then the above requirement shall not apply until after the patient has satisified the minimum deductible.
The health benefit plan also may not vary the out-of-pocket maximum or cost-sharing requirement, or otherwise design benefits accounting for the availability of a cost-sharing assistance program for a prescription drug.
If you believe an insurance company has failed to comply with 15–118.1, you can file a complaint with Maryland’s Department of Insurance.
Great news – Maine has passed restrictions on copay accumulators.
This law (24-A MRSA §4349, sub-§6) requires health insurance carriers and their pharmacy benefit managers to include cost-sharing amounts paid on behalf of a patient when calculating the patient’s contribution to any out-of-pocket maximum, deductible, or copayment when a drug does not have an alternative generic equivalent or was obtained through prior authorization, a step therapy override exception, or an exception or appeal process. The act’s requirements apply to prescription drug benefits provided pursuant to an insurance policy by a carrier or a PBM.
The bill also requires any third party that provides cost-sharing amounts paid on behalf of a patient to notify the covered person prior to or within 7 days of the acceptance of the financial assistance of the total amount of assistance available and the duration for which it is available, and cannot condition the assistance on enrollment in a specific health plan or type of health plan, except as permitted under federal law.
If you believe an insurance company has failed to comply with 24-A MRSA §4349, sub-§6, you can file a complaint with Maine’s Department of Insurance.
Great news – Louisiana has passed restrictions on copay accumulators.
This law (§22:976.1) requires health insurance issuers to include any cost-sharing amounts paid by the patient or on their behalf when calculating the enrollee’s contribution to any applicable cost-sharing requirement.
If you believe an insurance company has failed to comply with §22:976.1, you can file a complaint with Louisiana’s Department of Insurance.
Great news – Kentucky has passed restrictions on copay accumulators.
This law (§304.17A-164) prevents insurers from requiring a patient purchasing a prescription drug to pay a cost-sharing amount greater than the amount the insured would pay for the drug if the patient were to purchase without coverage. The law also prohibits the insurer from excluding any cost-sharing amounts paid by a patient or on behalf of a patient by another person for a prescription drug, when calculating an insured’s contribution to any applicable cost-sharing requirement.
The law does not apply in the case of a prescription drug that has a generic alternative, unless the insured has obtained access to the prescription drug through prior authorization, a step therapy protocol, or the insurer’s exceptions and appeals process. It also exempts fully insured or self-insured health benefit plans provided to state employees from the requirement that they count any cost-sharing amount paid by or on behalf of a patient.
If you believe an insurance company has failed to comply with §304.17A-164, you can file a complaint with Kentucky’s Department of Insurance.
Great news – Iowa has passed restrictions on copay accumulators.
Starting January 1, 2026, this law (Section 510B.8, Code 2025, Subsections 5 and 7) prohibits health plans from not including any amount paid by the enrollee or paid on behalf of the enrollee by another person when calculating an enrollee’s overall contribution to any out-of-pocket maximum or any cost-sharing requirement for a prescription drug under the health plan.
However, if the application of this provision would result in a health plan’s ineligibility to qualify as a Health Savings Account-qualified High Deductible Health Plan, then the above requirement shall not apply until after the patient has satisified the minimum deductible.
If you believe an insurance company has failed to comply with Section 510B.8, Code 2025, Subsections 5 and 7, you can file a complaint with Iowa’s Department of Insurance.
Great news – Indiana has passed restrictions on copay accumulators.
Starting January 1, 2026, this law (IC 27-1-24.5-27.7) requires health plans fto include any amount paid by the enrollee or paid on behalf of the enrollee by another person when calculating an enrollee’s overall contribution to any cost-sharing requirement for a prescription drug under the health plan. The health benefit plan also may not vary the out-of-pocket maximum or cost-sharing requirement, or otherwise design benefits accounting for the availability of a cost-sharing assistance program for a prescription drug.
However, if the application of this provision would result in a health plan’s ineligibility to qualify as a Health Savings Account-qualified High Deductible Health Plan, then the above requirement shall not apply until after the patient has satisified the minimum deductible.
If you believe an insurance company has failed to comply with IC 27-1-24.5-27.7, you can file a complaint with Indiana’s Department of Insurance.
Great news – Illinois has passed restrictions on copay accumulators.
This law (215 ILCS 134/30(d)) requires a health care plan to apply any third-party payments, financial assistance, discount, product vouchers, or any other reducation in out-of-pocket expenses made by or on behalf of a patient toward the patient’s deductible, copay, or cost-sharing responsibility, or out-of-pocket maximum.
If you believe an insurance company has failed to comply with 215 ILCS 134/30(d), you can file a complaint with Illinois’s Department of Insurance.
Great news – Georgia has passed restrictions on copay accumulators.
This law (§33-64-10) requires a pharmacy benefits manager to apply any third-party payment, financial assistance, discount, product voucher, or other reduction in out-of-pocket expenses made by or on behalf of an insured toward an insured’s cost share or copay responsibility.
If you believe an insurance company has failed to comply with O.C.G.A. §33-64-10, you can file a complaint with Georgia’s Department of Insurance.
Great news – Delaware has passed restrictions on copay accumulators.
This law (Title 18, § 3350B, § 3566A, § 3381A, and § 3382A) requires insurers to include any cost-sharing amounts paid by the patient or on behalf of the patient by another person, when calculating the patient’s contribution to any applicable cost-sharing requirement.
If doing so would result in Health Savings Account ineligibility under the federal Internal Revenue Code, then the requirement applies for HSA-qualified High Deductible Health Plans after the patient has satisfied the IRS minimum deductible — unless the services fall under preventative care per the Internal Revenue Code § 223(c)(2)(C).
If you believe an insurance company has failed to comply with Title 18, you can file a complaint with Delaware’s Department of Insurance.
Great news – Connecticut has passed restrictions on copay accumulators.
These law (Public Act No. 21-14 and HB 7192) require insurers to give credit for any discount provided or payment made by a third party for the amount of, or any portion of a patient’s coinsurance, copayment, deductible or other out-of-pocket expense. In addition, insurers must count a member’s out-of-pocket payments for prescription drugs toward in-network deductibles, copays, and coinsurance when the member pays a licensed pharmacy or provider directly without a claim, or buys the drug out of network, as long as the price paid is lower than the insurer’s average in-network cost and proof of payment is provided if required.
If you believe an insurance company has failed to comply with Public Act No. 21-14 or HB 7192, you can file a complaint with Connecticut’s Department of Insurance.
Great news – Colorado has passed restrictions on copay accumulators.
The law (§10-16-161) requires insurers to include any amount paid by the paitent or by another person on their behalf when calculating the patient’s overall contribution to their out-of-pocket maximum or cost-sharing requrement under the patient’s plan if:
– the prescription drug does not have a generic equivalent, biosimilar, or interchangeable biological product; or
– the prescription drug has a generic equivalent, biosimilar, or interchangeable biological product, but the patient is using the prescription and has (1) obtained prior authorization, (2) complied with a step therapy protocol, or (3) received approval through an exceptions and appeals process.
If a patient has obtained access to the drug through prior authorization, a step therapy protocol, or an exceptions and appeals process; the patient’s copay assistance must be counted by their insurer.
If you believe an insurance company has failed to comply with §10-16-161 you can file a complaint with Colorado’s Department of Insurance.
Great news – Arkansas has passed restrictions on copay accumulators.
The law (Arkansas Code Title 23, Chapter 79, Subchapter 21) requires insurers to count any cost-sharing amounts paid by the patient or on behalf of the patient when calculating a patient’s cost-sharing contribution. The cost-sharing requirement does not apply if a name-brand prescription drug is prescribed and it:
– is not considered to be medically necessary by the prescriber; or
– has a medically appropriate generic equivalent.
This law applies to state-regulated commercial plans, Arkansas public employee plans, and Arkansas’s Medicaid expansion program, Arkansas Health and Opportunities for Me (ARHOME).
If you believe an insurance company has failed to comply with Arkansas Code Title 23, Chapter 79, Subchapter 21, you can file a complaint with Arkansas’s Department of Insurance.
Washington has some non-medical switching protections for prescription drugs related to mental health.
This law (RCW 48.43.0961) states that a health carrier or health care benefit manager may not require the substitution of a nonpreferred drug with a preferred drug in a given therapeutic class, or increase a patient’s cost-sharing obligation mid-plan year for the drug, if the prescription is for a refill of an antipsychotic, antidepressant, antiepileptic, or other drug prescribed to the patient to treat a serious mental illness, the patient is medically stable on the drug, and a participating provider continues to prescribe the drug.
The carrier of the plan can still require generic substitution during the current plan year, the carrier of the plan can still add new drugs to its formulary during the current plan year, and the carrier can still remove a drug from its formulary for reasons of patient safety or efficacy concerns. A participating provider can still prescribe a different drug that is covered by the plan and medically approriate for the patient.
If you believe an insurance company has failed to comply with RCW 48.43.0961, you can file a complaint with Washington Department of Insurance.
Great news – Texas has some non-medical switching protections.
This law (Title 8, Sec. 1369.0541 & Sec. 1369.055) requires that, at least 60 days prior to modifying a formulary, a health benefit plan must provide written notice of the modification to each affected enrollee in an affected group health benefit plan, and each affected individual health benefit plan holder. A health benefit plan issuer also may not modify drug coverage provided under a health benefit plan unless the modification occurs at the time of coverage renewal, and is uniform across the plan. In addition, a health benefit plan issuer must offer an enrollee coverage of a drug at the contracted benefit level, regardless of whether the drug has been removed from the plan’s formulary before the plan renewal date, if the enrollee was previously approved or covered for the drug under the plan. This regulation applies until the date of plan renewal.
If you believe an insurance company has failed to comply with Section 1369.054-1, you can file a complaint with Texas Department of Insurance.
Great news – Rhode Island has non-medical switching protections.
This law (S2294A) requires insurers to give 30 days notice before making changes in preferred or tiered cost sharing status of covered drugs. Any drug that is deemed unsafe may be removed immediately without prior notice.
If you believe an insurance company has failed to comply with S2294A, you can file a complaint with Rhode Island’s Department of Insurance.
Great news – New York has non-medical switching protections.
This law (ISC Chapter 28, Article 32, Section 3242) health care plans must provide notice to policyholders 30 days prior to open enrollment of intent to make any of the formulary changes below for a prescription drug during the ensuing plan year. Health care plans cannot 1) remove a prescription drug from formulary during the plan year, 2) move a prescription drug to a tier with a larger deductible, copayment, or coinsurance during the plan year, or 3) add new utilization management requirements during the plan year. However, if an AB-rated generic equivalent or interchangable biosimilar is added to the formulary, the prohibition on moving tiers does not apply.
Great news – New Mexico has non-medical switching protections.
This law (NM Stat § 13-7-15) prevents health plans from making any of the following changes to coverage for a prescription drug within 120 days of any previous change to coverage for that prescription drug, unless a generic version of the drug is available.
The changes include: (1) reclassifying a drug to a higher tier of the formulary, (2) reclassifying a drug from a preferred classification to a non-preferred classification, unless it is moving the drug to a lower tier on the formulary, (3) increasing the cost-sharing, copayment, deductible or co-insurance charges for a drug, (4) removing a drug from the formulary, (5) establishing a prior authorization requirement, (6) imposing or modifying a drug’s quantity limit, or (7) imposing a step therapy restriction.
If you believe an insurance company has failed to comply with NM Stat § 13-7-15, you can file a complaint with New Mexico’s Department of Insurance.
Nevada has non-medical switching protections.
This law (NAC 689A.425 and NRS 689A.04045) prohibits health plans from making certain formulary changes during the course of a plan year, including 1) removing a prescription drug from the formulary and 2) moving a drug to a tier with a larger deductible, copayment, or coinsurance (a health plan subject to 689A.425 may still remove a drug from their formulary during a plan year under certain circumstances such as when the plan adds a generic approved by the FDA for use as an alternative to the brand name drug to their formulary). In addition, issuers of individual policies may not limit or reduce coverage for a prescription drug that has been previously approved for coverage for an insured during term of their policy if 1) the insured’s health care provider reasonably determines that none of the alternative drugs approved for coverage are medically appropriate and 2) the drug is appropriately prescribed and considered safe for treating the insured’s medical condition.
If you believe an insurance company has failed to comply with NAC 689A.425 and NRS 689A.04045, you can file a complaint with Nevada’s Department of Insurance.
Montana has passed protections from non-medical switching.
This law (SB 449) mandates that when enrollees switch health plans, prior authorizations granted by their previous insurer must be honored for at least the first 90 days of the new coverage, with certain exceptions and subject to the terms of the new plan.
If you believe an insurance company has failed to comply with SB 449, you can file a complaint with Montana Department of Insurance.
“Maryland has non-medical switching protections.
This law (Chapter 503) requires any entity that removes a drug from its formulary or moves it to a benefit tier that requires a patient to pay a higher deductible, copayment, or coinsurance amount provides a patient with (1) notice of the change at least 30 days before the change is made, and (2) notice of the process for requesting an exemption.
If you believe an insurance company has failed to comply with Chapter 503, you can file a complaint with Maryland’s Department of Insurance.
Maine has non-medical switching protections.
This law (24-A MRSA §4311, sub-§1) requires that a health plan provides an enrolled patient with at least 60 days’ written notice of an adverse change to a formulary, meaning a change that removes a drug currently prescribed from the formulary or moving the drug to a different tier with a higher cost-sharing requirement.
If a drug is removed from a formulary, the health plan must notify the patient of their ability to request an exception and provide a form for the patient to use to request an exception. If a patient has already received prior authorization for that drug, the health plan shall continue to honor the existing authorization until it expires. However, the aformementioned do not apply when a drug has been removed because of safety concerns.
If you believe an insurance company has failed to comply with 24-A MRSA §4311, sub-§1, you can file a complaint with Maine’s Department of Insurance.
Louisiana has non-medical switching protections.
This law (§ 1060.1) requires insurers to provide in plain language (1) notice that the plan uses one or more drug formularies, (2) an explanation of what a drug formulary is, (3) a statement regarding the method the health insurer uses to determine the drugs to be included in or excluded from a drug formulary, (4) a statement of how often the health insurer reviews the contents of each drug formulary, and (5) notice that a patient may contact the insurer to determine whether a drug is included in a particular formulary.
An insurer must offer any enrolled patient any drug that was approved or covered at the contracted benefit level and until the patient’s plan renewal date, regardless of whether the drug has been removed from the plan’s formulary before the plan renewal date.
If you believe an insurance company has failed to comply with § 1060.1, you can file a complaint with Louisiana’s Department of Insurance.
Iowa has non-medical switching protections.
This law (§ 514F.9) prevents health carriers, health benefit plans, or utilization review organizations from limiting or excluding coverage of a prescription drug for any covered patient who is medically stable on a drug as determined by a health care professional, if all of the following apply (1) the prescription drug was previously approved by the health carrier; (2) the prescriber has prescribed the drug within the last six months, (3) the patient continues to be an enrollee of the plan.
If you believe an insurance company has failed to comply with § 514F.9 you can file a complaint with Iowa’s Department of Insurance.
Indiana has passed protections from non-medical switching.
This law (Public Law 19) prevents state employee health plans from removing a prescription drug from its formulary, changing the cost sharing requirements for a prescription drug, or changing the utilization review requirements for a prescription drug unless the plan does at least one of the following: (1) send written notice of the removal or change to the patient at least 60 days before effective date; (2) send written notice of the removal or change and a 60 day supply of the prescription drug if the patient has been prescribed the drug during the preceding 12 month period and has requested a refill.
This law applies to both state-regulated health commercial plans and state public employee plans.
If you believe an insurance company has failed to comply with Public Law 19, you can file a complaint with Indiana’s Department of Insurance.
Illinois has passed protections from non-medical switching.
This law (215 ILCS 134/25) states that a health care plan cannot remove a drug from its formulary or alter its preferred or cost-tier sharing unless 60 days notice is given before the change, including (1) general notification to current and prospective enrollees; 2) direct notification to enrollees currently using the drug, explaining how to request coverage determinations and exceptions including the option for enrollees to continue coverage if a prescribing provider certifies medical necessity; and 3) direct notification to prescribing providers about affected enrollees, with a form to certify medical necessity. If the prescribing provider certifies a drug’s medical necessity, the health plan must continue coverage without increasing costs, restricting the drug to a higher tier, or denying the drug for ongoing coverage.
If you believe an insurance company has failed to comply with 215 ILCS 134/25, you can file a complaint with Illinois’s Department of Insurance.
Florida has passed protections from non-medical switching.
This law (Chapter No. 2023-29) requires pharmacy benefit managers to, upon revising their formularies of covered prescription drugs during a plan year, provide a 60-day continuity-of-care period, and the covered prescription drug must be provided at the same cost for the patient for a period of 60 days. The 60-day continuity-of-care period starts when the patient is notified.
“Connecticut has passed protections from non-medical switching.
This law (Public Act No. 21-96) prohibits health carriers from (1) removing a prescription drug from the drug formulary or list of covered drugs during a plan year; or (2) moving a prescription drug from a lower cost-sharing tier to a higher cost-sharing tier during a plan year unless the drug is subject to an in-network coinsurance, copayment or deductible that is $40 or less per prescription per month in any tier. It does allow for formulary changes if a generic or biosimilar drug is added at a lower cost.
If you believe an insurance company has failed to comply with Public Act No. 21-96, you can file a complaint with Connecticut’s Department of Insurance.
“Colorado has passed protections from non-medical switching.
This law (§10-16-122.4) requires insurers who use pharmacy benefit managers (PBMs) cannot change their drug formulary (list of drugs the plan covers) in the middle of a current plan year. It does allow for formulary changes if a generic or biosimilar drug is added at a lower cost, or if a drug’s cost increases significantly, provided advance notice is given.
If you believe an insurance company has failed to comply with §10-16-122.4 you can file a complaint with Colorado’s Department of Insurance.
“California has passed protections from non-medical switching.
This law (California Health and Safety Code, Section 1367.22) prohibits health care service plans (aka HMOs) from limiting or excluding coverage for a drug for an enrollee that has previously had the drug approved for coverage by the plan (Note: This section does not prohibit generic substitutions as authorized under Section 4073 of the Business and Professions Code).
If you believe an insurance company has failed to comply with Section 1367.22 you can file a complaint with California’s Department of Insurance.
Arizona has passed protections from non-medical switching.
Starting in 2026, this law (ARS Title 20, Chapter 25, Article 2, Sections 20-3335 and 20-3336) prevents insurers from limiting or excluding prescription drug coverage for individuals who are already on specific medications within the same health care plan year. If a formulary change occurs, the insurer must notify affected individuals and their prescribing health care providers at least 60 days in advance, detailing the process for maintaining coverage of non-formulary drugs.
If you believe an insurance company has failed to comply with ARS Title 20, Chapter 25, Article 2, Sections 20-3335 and 20-3336, you can file a complaint with Arizona’s Department of Insurance.
The state of Washington has enacted government price-setting legislation. This law (SB 5532) creates a Prescription Drug Affordability Board (PDAB) that has the authority to review prescription drug costs through affordability reviews and then implement recommendations, including setting an upper payment limit (UPL) for certain prescription drugs. The Washington PDAB has authority to set UPLs for both public health plans and state-regulated commercial plans.
The state of Vermont has enacted government price-setting legislation. These laws (S 126 and S 98) empowers the Green Mountain Care Board (GMCB) to implement reference-based pricing based on percentage of Medicare for services delivered outside a hospital by setting the minimum amounts that shall be paid for items provided and services delivered by nonhospital-based health care professionals, starting in 2027. GMCB is also tasked with developing a plan to regulate drug costs, taking into consideration of state PDAB activities and the Medicare Drug Price Negotiation Program.
The state of Oregon has enacted government price-setting legislation. This law (ORS 646A.693-697) creates a Prescription Drug Affordability Board (PDAB) that has the authority to review prescription drug costs through affordability reviews and then implement recommendations. The Oregon PDAB does not have the authority to set UPLs, but has jurisdiction over both public health plans and state-regulated commercial plans.
The state of New Jersey has enacted government price-setting legislation. This law (P.L. 2023, c. 106) creates a Drug Affordability Council that has the authority to review prescription drug costs through affordability reviews and then implement recommendations. The New Jersey PDAB does not have the authority to set UPLs, but has jurisdiction over both public health plans and state-regulated commercial plans.
The state of Minnesota has enacted government price-setting legislation. This law (62J.87; Minnesota 2023 Laws, Chapter 57, Article 2, Section 30) creates a Prescription Drug Affordability Board (PDAB) that has the authority to review prescription drug costs through affordability reviews and then implement recommendations, including setting an upper payment limit (UPL) for certain prescription drugs. The Minnesota PDAB has authority to set UPLs for both public health plans and state-regulated commercial plans.
The state of Maryland has enacted government price-setting legislation. These laws (MD Health – General Code § 21-2C and SB 357/HB 424 HB 23-1225) create a Prescription Drug Affordability Board (PDAB) that has the authority to review prescription drug costs through affordability reviews and then implement recommendations, including setting an upper payment limit (UPL) for certain prescription drugs. The Maryland PDAB has authority to set UPLs for both public health plans and state-regulated commercial plans.
The state of Maine has enacted government price-setting legislation. This law (MRS Title 5 Chapter 167-1) create a Prescription Drug Affordability Board (PDAB) within the ME Office of Affordable Health Care that has the authority to review prescription drug costs through affordability reviews and then implement recommendations. The Maine PDAB is limited to implementing government price-setting policies in public health plans, does not have the authority to set UPLs.
The state of Colorado has enacted government price-setting legislation. These laws (SB 21-175 and HB 23-1225) create a Prescription Drug Affordability Board (PDAB) within the CO Division of Insurance that has the authority to review prescription drug costs through affordability reviews and then implement recommendations, including setting an upper payment limit (UPL) for certain prescription drugs. The Colorado PDAB has authority to set UPLs for both public health plans and state-regulated commercial plans.
Great news – Mississippi has enacted a law restricting white bagging.
The law (HB 17) states that PBMs are prohibited from:
(a) Refusing to authorize, approve, or pay a provider for providing covered physician-administered drugs and related covered services to patients; or
(b) Requiring a patient to pay any penalty or additional fee (in addition to the cost-sharing amounts required by the patient as outlined within their health plan) to obtain the physician-administered drug when provided by a participating provider.
If you believe an insurance company has failed to comply with HB 17, you can file a complaint with Mississippi’s Department of Insurance.
Great news – Arkansas has enacted a law restricting or prohibiting white bagging.
The Arkansas (AR Code § 23-99-1503) law only applies to hematology and oncology patients. However, the Arkansas insurance commissioner has the power to expand the law to cover more conditions. This law states that a provider may make the determination whether it is in the best interest of the patient to bill their healthcare payer (under the patient’s medical benefit) or pharmacy benefits carrier (under the patient’s pharmacy benefit) for drugs ordinarily covered by the payer. The payer must reimburse for the cost and administration of the drug through the medical or pharmacy benefit, as determined by the provider.
If you believe an insurance company has failed to comply with AR Code § 23-99-1503, you can file a complaint with Arkansas’s Department of Insurance.
Great news – Louisiana has enacted a law restricting or prohibiting white bagging.
The law (La. Stat. Ann. § 22:1020.53) states that if medical necessity criteria are met, an insurer or PBM may not condition, deny, restrict, or refuse to authorize or refuse to approve a provider for a medically necessary, clinician-administered drug because the provider obtained the drug from a pharmacy that is not an insurer’s network pharmacy or a PBM’s network pharmacy. PBMs are also prohibited from requiring a covered person to pay an additional fee, or any other increased cost-sharing amount (in addition to the cost-sharing designated within their health plan) to obtain the physician-administered drug when provided by a participating provider.
If you believe an insurance company has failed to comply with La. Stat. Ann. § 22:1020.53, you can file a complaint with Louisiana’s Department of Insurance.
Great news – Minnesota has enacted a law restricting white bagging.
The Minnesota law states that PBMs or health carriers requiring clinician-administered drugs to be obtained from a specialty pharmacy establish and disclose a process for the healthcare provider to appeal and make exceptions if:
1. The drug is not delivered on the date/time and at the location as requested by the provider OR
2. The healthcare provider believes an enrollee may experience immediate and irreparable harm without immediate one-time use of the drug the provider has in stock.
If you believe an insurance company has failed to comply with Chapter 62W.15 (2024 Minnesota Statutes), you can file a complaint with Minnesota’s Department of Insurance.
Great news – Nebraska has enacted a law restricting white bagging.
The law (LB 198) states that PBMs or health carriers requiring clinician-administered drugs to be obtained from a specialty pharmacy establish and disclose a process for the healthcare provider to appeal and make exceptions if:
In addition:
If you believe an insurance company has failed to comply with LB 198, you can file a complaint with Nebraska’s Department of Insurance.
Great news – North Dakota has enacted a law prohibiting white bagging.
This law (19-02.1-16.6) prohibits PBMs and third-party payers from requiring by contract, policy, or procedure that a pharmacy designated by the PBM dispense a medication directly to a health care setting for a participating provider to administer to a patient. PBMs and third-party payers also many not condition, deny, restrict, refuse to authorize, or reduce payment to a provider for clinician-administered drugs not obtained through a mail-order pharmacy or PBM affiliate.
If you believe an insurance company has failed to comply with 19-02.1-16.6, you can file a complaint with North Dakota’s Department of Insurance.
Great news – Ohio has enacted a law prohibiting white bagging.
This law (Ohio Rev. Code § 5167.24(4)) states that the state PBM contracted with Ohio Medicaid is prohibited from requiring a Medicaid recipient to obtain a specialty drug from a specialty pharmacy owned or otherwise associated with the state PBM.
If you believe an insurance company has failed to comply with Ohio Rev. Code § 5167.24(4), you can file a complaint with Ohio’s Department of Insurance.
Great news – Oklahoma has enacted a law ensuring reimbursement for provider-administered drugs. However, Oklahoma does not prohibit PBMs from engaging in white bagging.
This law (HB 1713) states that a) PBMs are prohibited from refusing to authorize, approve, or pay a participating provider for providing covered provider-administered drugs to patients; and b) providers are allowed to dispense and administer a covered provider-administered drug based on a patient’s best interest, provided that the provider that administers the drug agrees to the terms and conditions of network participation and accept, as payment in full, reimbursement for the drug at the PBM’s negotiated contracted rate.
If you believe an insurance company has failed to comply with HB 1713, you can file a complaint with Oklahoma’s Department of Insurance.
Great news – Rhode Island has enacted a law restricting or prohibiting white bagging.
The Rhode Island law states that a health insurer or third party cannot review to authorize, approve, or pay a provider for clinician-administered drug that was administered and dispensed by any in-network hospital or clinic as long as the dispensing and administrating and any authorization and approvals are consistent with the provider contract and issuer’s medical and payment policies.
If you believe an insurance company has failed to comply with RI Gen L § 27-18-33.3., you can file a complaint with Rhode Island’s Department of Insurance.
Great news – Texas has enacted a law restricting or prohibiting white bagging.
The Texas law states that an insurer may not, for enrollees with chronic, complex, rare, or life-threatening conditions, require clinician-administered drugs to be dispensed only by certain pharmacies if the drug is otherwise covered. Additionally, the insurer may not require that an in-network provider bill for or be reimbursed for delivery and administration under the pharmacy benefit instead of medical beenfit without written consent from the patient and written attestation by the health care provider that a delay in administration would not put the patient’s health at increased risk.
If you believe an insurance company has failed to comply with § 1369.764, you can file a complaint with Texas’s Department of Insurance.
Great news – Vermont has enacted a law restricting or prohibiting white bagging.
The Vermont law states that a health insurer or PBM may not require that a pharmacy designated by the insurer or PBM dispense a medication directly to a health care setting for a provider to administer to the patient.
If you believe an insurance company has failed to comply with 8 V.S.A. § 4089j, you can file a complaint with Vermont’s Department of Insurance.
Great news – Virginia has enacted a law restricting or prohibiting white bagging.
The Virginia law states that a health insurer or PBM cannot prohibit anyone receiving pharmacy benefits, including specialty pharmacy benefits, from selecting the pharmacy of their choice, including nonpreferred or nonparticipating providers.
If you believe an insurance company has failed to comply with § 38.2-3407.7. Pharmacies; freedom of choice, you can file a complaint with Virgnia’s Department of Insurance.
Great news – Alaska has enacted a law restricting or prohibiting white bagging.
The law (Sec. 21.27.951) states that if medical necessity criteria are met, an insurer or PBM may not condition, deny, restrict, or refuse to authorize or refuse to approve a provider for a clinician-administered drug because the provider obtained the drug from a pharmacy that is not an insurer’s network pharmacy or a PBM’s network pharmacy. Insurers and PBMs are also prohibited from refusing to authorize, approve, or pay a provider for providing covered clinician-administered drugs to a patient if the provider has agreed to participate in the insurer’s health care insurance policy according to the terms offered by the insurer or its pharmacy benefits manager.
If you believe an insurance company has failed to comply with Sec. 21.27.951, you can file a complaint with Alaska’s Department of Insurance.
The District of Columbia has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a health care provider can request an exception.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Wyoming has step therapy protections.
This law (26-55-111) prohibits insurers from requiring patients to repeat a step therapy protocol if the patient already tried the protocol’s required medication (or another similar one) under a current or past plan and stopped because the drug was ineffective or caused an adverse reaction.
If you believe an insurance company has failed to comply with 26-55-111, you can file a complaint with Wyoming’s Department of Insurance.
Great news – Wisconsin has step therapy protections.
This law (§632.866) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 3 business days granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond by the end of next business day. If they do not provide a response within the timeline, the exception request shall be deemed approved.
Wisconsin’s step therapy protections include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §632.866, you can file a complaint with Wisconsin’s Department of Insurance.
Great news – West Virginia has step therapy protections.
This law (§33-15-40) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §33-15-40, you can file a complaint with West Virginia’s Department of Insurance.
Great news – Washington has step therapy protections.
This law (RCW 48.43.420) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 3 business days granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with RCW 48.43.420, you can file a complaint with Washington’s Department of Insurance.
If you believe an insurance company has failed to comply with §38.2-3407.9:05, you can file a complaint with Virginia’s Department of Insurance.
Great news – Virginia has step therapy protections.
This law (§38.2-3407.9:05) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §38.2-3407.9:05, you can file a complaint with Virginia’s Department of Insurance.
Great news – Vermont has step therapy protections.
This law (8 V.S.A. § 4089i) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to a completed exception request with a decision within 2 business days. In cases of emergency, the insurer must respond to a completed exception request with a decision within 24 hours. Insurers must also notify that they received the request and if any information is missing within 24 hours. If the insurer does not respond within these prescribed timeframes with a denial or request for more information, the exception shall be deemed granted.
If you believe an insurance company has failed to comply with 8 V.S.A. § 4089i, you can file a complaint with Vermont Department of Insurance.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Texas has step therapy protections.
This law (Title 8, Subtitle E, Chapter 1369.0546) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Title 8, Subtitle E, Chapter 1369.0546, you can file a complaint with Tennessee Department of Insurance.
Great news – Tennessee has step therapy protections.
This law (Chapter No. 1020) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 2 business days granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours.
Protections in Tennessee include Medicaid and marketplace plans.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Chapter No. 1020, you can file a complaint with Tennessee Department of Insurance.
Great news – South Dakota has step therapy protections.
This law (58-17H-55) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 5 calendar days granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 72 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with 58-17H-55, you can file a complaint with South Dakota’s Department of Insurance.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
The state of Rhode Island has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Pennsylvania has step therapy protections.
This law (P.L. 2068, No. 146, Section 2156) requires insurers to consider granting an exception, taking into account if:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 2 business days, but not more than 72 hours total, granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours.
Protections in Pennsylvania include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with P.L. 2068, No. 146, Section 2156, you can file a complaint with Pennsylvania Department of Insurance.
Great news – Oregon has step therapy protections.
This law (ORS 743B.602) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours or 2 business days (whichever is later) granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 1 business day. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with ORS 743B.602, you can file a complaint with Oregon’s Department of Insurance.
Great news – Oklahoma has step therapy protections.
This law (63 OK Stat § 7310) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
Protections in Oklahoma include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with 63 OK Stat § 7310, you can file a complaint with Oklahoma’s Department of Insurance.
Great news – Ohio has step therapy protections.
These laws (Section 3901.832, and Section 5164.7514) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 10 calendar days granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 48 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
Protections in Ohio include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Section 3901.832 (Medicaid) or Section 5164.7514 (commercial health plans, you can file a complaint with Ohio’s Department of Insurance.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healt care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – North Carolina has step therapy protections.
This law (§58-3-221) requires insurance companies to grant a step therapy exception if a provider demonstrates either of the following:
A provider can file an exception if the situation matches any of the above criteria.
The insurer must respond within 72 hours indicating whether the step therapy exception request has been approved, denied, or they require more information.
In emergency cases, the insurer must respond within 24 hours.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §58-3-221, you can file a complaint with North Carolina’s Department of Insurance.
Great news – New York has step therapy protections.
This law (§4903) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 72 hours indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
Protections in New York include Medicaid Managed Care plans (not fee-for-service plans).
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Insurance Law §4903, you can file a complaint with New York’s Department of Insurance.
Great news – New Mexico has step therapy protections.
This law (NM Stat § 13-7-18 [2024] and Section 59A-22B-8 NMSA 1978) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 72 hours indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
Step therapy is prohibited for 1) drugs treating autoimmune conditions except in cases in which a biosimilar, interchangeable biologic or generic version is available, or 2) an off-label medication that is prescribed for the treatment of a rare disease or condition (affecting less than 200,000 people in the US).
Protections in New Mexico include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with NM Stat § 13-7-18 (2024) and/or Section 59A-22B-8 NMSA 1978, you can file a complaint with New Mexico’s Department of Insurance.
Great news – New Jersey has step therapy protections.
Starting January 1, 2026, this law (C.30:4D-7xx and C.52:14-17.28j) requires New Jersey Medicaid , the State Health Benefits Program, and the School Employees’ Health Benefits Program to grant a step therapy exception if a healthcare provider demonstrates any of the following:
If granted, the insurer shall authorize coverage for the drug prescribed by the patient’s provider at least 180 days or the duration of therapy if less than 180 days, provided that the drug is covered by the patient’s health plan.
The insurer must respond within 72 hours indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with C.30:4D-7xx and C.52:14-17.28j, you can file a complaint with New Jersey’s Department of Insurance.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Nevada has step therapy protections.
This law (NRS 689A.04043) requires insurers to grant an exception if a health care provider demonstrates any of the following:
A health care provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within two business days indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with NRS 689A.04043, you can file a complaint with Nevada’s Department of Insurance.
Great news – Nebraska has step therapy protections.
This law (§44-7,115) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within five days indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 72 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §44-7,115, you can file a complaint with Nebraska’s Department of Insurance.
If a patient has been subjected to step therapy, a health care provider can request an exception.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Missouri has step therapy protections.
This law (376.2034) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with 376.2034, you can file a complaint with Missouri’s Department of Insurance.
Great news – Mississippi has step therapy protections.
This law (§83-9-36) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §83-9-36, you can file a complaint with Mississippi’s Department of Insurance.
Great news – Minnesota has step therapy protections.
This law (62Q.184) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 5 days indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 72 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with 62Q.184, you can file a complaint with Minnesota’s Department of Insurance.
The state of Michigan has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Massachusetts has step therapy protections.
This law (Chapter 254) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 3 business days indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Chapter 254, you can file a complaint with Massachusetts’s Department of Insurance.
Great news – Maryland has step therapy protections.
This law (Insurance Article §15-142) requires an insurer to grant a step therapy exception if your healthcare provider:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Insurance Article §15-142, you can file a complaint with Maryland’s Department of Insurance.
Great news – Maine has step therapy protections.
This law (24-A MRSA §4320-L) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 72 hours or 2 business days (whichever is less) indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with 24-A MRSA §4320-L, you can file a complaint with Maine’s Department of Insurance.
Great news – Louisiana has step therapy protections.
This law (§22:1053 and §460.34) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 72 hours indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
Protections in Louisiana include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §22:1053 (private plans) or §460.34 (Medicaid), you can file a complaint with Louisiana’s Department of Insurance.
Great news – Delaware has step therapy protections.
This law (Title 18 § 3381) requires insurers to grant a step therapy exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria. If a patient is currently stable, exception requests are deemed granted until determined otherwise by the insurer.
An insurer must respond within 2 business days letting a patient know whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Title 18 §3381, you can file a complaint with Delaware’s Department of Insurance.
Great news – Kentucky has step therapy protections.
This law (§304.17A-163) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 48 hours indicating whether the step therapy exception request has been approved, denied, or they require more information. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §304.17A-163, you can file a complaint with Kentucky’s Department of Insurance.
Great news – Kansas has step therapy protections, but only for Medicaid.
This law (39-7,121) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 72 hours that the step therapy exception has been approved, denied, or they require more information.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with 39-7,121, you can file a complaint with Kansas’s Department of Insurance.
Great news – Iowa has step therapy protections.
This law (§514F.7 Iowa Code) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within five calendar days indicating whether the step therapy exception request has been approved, denied, or they require more information.
In emergency cases, the insurer must respond within 72 hours.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §514F.7 Iowa Code, you can file a complaint with Iowa’s Department of Insurance.
Great news – Indiana has step therapy protections.
This law (IC 27-8-5-30, IC 27-13-7-23, or IC 5-10-8-17) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
Indiana step therapy protections include state-regulated accident & sickness plans, state-regulated commercial health plans, and public employee plans.
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
An insurer must respond within 3 business days letting a patient know whether their step therapy exception request has been approved, denied, or they require more information.
In emergency cases, the insurer must respond within 1 business day.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with IC 27-8-5-30 (accident & sickness plans), IC 27-13-7-23 (commercial health plans), or IC 5-10-8-17 (public employee plans), you can file a complaint with Indiana’s Department of Insurance.
Great news – Illinois has step therapy protections.
These laws (§215 ILCS 134/45.1 and §215 ILCS 5/356z.80) require insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
An insurer must respond within 72 hours letting a patient know whether their step therapy exception request has been approved, denied, or they require more information.
In emergency cases, the insurer must respond within 24 hours.
State-regulated commercial and managed care plans are also specifically prohibited from imposing step therapy requirements on treatments for Alzheimer’s.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §215 ILCS 134/45.1 and/or §215 ILCS 5/356z.80, you can file a complaint with Illinois’s Department of Insurance.
The state of Hawaii has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a healthcare provider can request an exception.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Georgia has step therapy protections.
This law (O.C.G.A. § 33-24-59.25) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
An insurer must respond within two business days notifying a patient that the exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with O.C.G.A. § 33-24-59.25, you can file a complaint with Georgia’s Department of Insurance.
Great news – Florida has step therapy protections.
This law (Title XXXVII, ss. 627.42393) requires insurers to grant a step therapy exception if a healthcare provider demonstrates that a patient has previously completed a step therapy protocol with another health plan, and the plan paid for the requested drug during the 90 days preceding this request.
If an insurer does deny an exception request, a healthcare provider has the right to file an appeal on behalf of a patient. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with ss. 627.42393, you can file a complaint with Florida’s Department of Insurance.
Great news – Connecticut has step therapy protections.
These laws (Chapter 700C, Sections 38A-510 and 38A-544) require insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria. Starting January 1, 2026, insurers are prohibited from requiring step therapy for longer than 30 days for drugs treating multiple sclerosis or rheumatoid arthritis. After this period, the provider may deem that treatment ineffective and authorize dispensation of and coverage for the drug originally prescribed by the provider, provided the drug is covered under the patient’s health plan. Protections in Connecticut include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal. If you believe an insurance company has failed to comply with Chapter 700C, Section 38A-510 or Section 38A-544, you can file a complaint with Connecticut’s Department of Insurance.
Great news – Colorado has step therapy protections.
This law (Colo. Rev. Stat. § 10-16-145) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria. The insurer must respond to an exception request within three business days stating whether the request is approved, denied, or they need more information. In emergency cases, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with HB 1370, you can file a complaint with Colorado’s Department of Insurance.
Great news – California has step therapy protections.
This law (§1367.206) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §1367.206, you can file a complaint with California’s Department of Insurance.
Great news – Arkansas has step therapy protections.
This law (§23-79-2104) requires an insurer to grant a step therapy exception if a healthcare provider demonstrates that:
An insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §23-79-2104, you can file a complaint with Arkansas’s Department of Insurance.
Great news – Arizona has step therapy protections.
This law (§20-3654) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §20-3654, you can file a complaint with Arizona’s Department of Insurance.
Great news – Alaska has step therapy protections starting January 1, 2027.
This law (AS Sec. 21.07.160) requires insurers to provide a patient and their provider with access to a clear, convenient, and readily accessible process for requesting an exception to application of the step therapy protocol. Insurers may use its existing medical exceptions process to satisfy this requirement. Insurers are required to disclose the process to the patient and their provider, along with the information needed to process the request, and make the process available on the insurer’s website.
Insurers are required to grant a step therapy exception if:
Use of drug samples from a pharmacy may not be considered trial and failure of a preferred prescription drug required under a step therapy protocol.
Insurers may request information from the patient or their provider to support a step therapy exception request. Upon granting a step therapy exception request, the insurer shall authorize dispensation of and coverage for the prescription drug prescribed by the patient’s provider if the drug is covered under the health plan.
If you believe an insurance company has failed to comply with AS Sec. 21.07.160, you can file a complaint with Alaska’s Department of Insurance.
The state of Alabama has yet to pass step therapy reform. Contact your state legislators and ask for their support.