Back to Insights and Updates for ProvidersMarch 2024

Reminder: Step therapy protocols and exceptions

Harvard Pilgrim Health Care Commercial  |  Tufts Health Direct  |  Tufts Health Plan Commercial

As previously announced in the October issue of Insights and Updates for Providers, Massachusetts law states that the clinical review criteria used to establish a step therapy protocol cannot require members to utilize a medication that is not likely to be clinically effective for the prescribed purpose. As a result, Massachusetts law now requires mandatory exceptions in step therapy protocols.

To support the step therapy exceptions request process, the Massachusetts Division of Insurance recently updated the MA Standard Form for Medication Prior Authorization Requests and the MA Standard Form for Chemotherapy and Supportive Care Prior Authorization Requests. The MA Standard Form for Hepatitis C Medication Prior Authorization Requests is also in the process of being updated. You can access the latest versions of these forms in the pharmacy section on our website.

Health plans are required to process step therapy exceptions and appeals within 3 business days following the receipt of all necessary information needed to make a medical necessity determination. For urgent requests, health plans are required to respond back within 24 hours following the receipt of all necessary information if additional delay would result in significant risk to the member’s health or well-being. For expedited step therapy appeals, please mark the subject line as “24 hours – Expedited”.

If a member has already been prescribed and is stable on a drug subject to step therapy requirements, we will allow a one-time transition fill for up to a 30-day supply of the requested drug while an exception to the step therapy request is being reviewed.

To learn more about our pharmacy program, please refer to the pharmacy section of our provider website, Harvard Pilgrim Commercial Provider Manual, Tufts Health Plan Commercial Provider Manual, and Tufts Health Public Plans Provider Manual.

Audrey Kleinberg,
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