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, MA law now requires mandatory exceptions in step therapy protocols effective Oct. 1, 2023.
For commercial members, 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 MassHealth members, health plans are required to process step therapy exceptions and appeals within 24 hours following the receipt of all necessary information. For urgent requests for all members, health plans are required to respond back within 24 hours following the receipt of all necessary information.
Point32Health’s pharmacy program already allows for providers to submit step therapy exceptions. For more information on how to submit step therapy exceptions, visit the Harvard Pilgrim Health Care and Tufts Health Plan provider websites.
To simplify the step therapy exception process for providers, MassHealth and the Mass Collaborative are working on updating applicable prior authorization request forms. Visit our websites to access the latest versions of these forms.
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Joseph O’Riordan, Susan Panos, Stephen Wong,