Insurers would let eligible patients bypass try-first drug rules

Insurers and organizations that review coverage would grant exceptions to rules requiring patients to try medicines in a set order. The rules would cover state-regulated plans that cover prescription drugs and require patients to try them in a set order, whatever the policy is called. An exception would apply when a medicine stabilizes the patient's condition and their provider prescribes continued use, regardless of current or past insurance coverage. If the condition is not stable, an exception would apply when a required medicine would likely harm the patient, is expected to be ineffective, or is unsuitable based on medical need. An exception would also apply to an unstable condition when the required medicine, or one that works the same way, was stopped because it failed or caused an adverse event. Insurers could require an equivalent generic or interchangeable biological medicine first unless the patient qualifies for an exception. Once an exception is granted, the insurer or coverage reviewer would authorize coverage of the medicine prescribed by the patient's provider.

Insurers and coverage reviewers would offer a clear exception process accessible through their websites and provide their medical review rules upon written request. Patients and prescribers in covered state-regulated plans could request exceptions. Existing exception or appeal processes could be used if they meet these requirements. Coverage denials could be appealed. For incomplete requests or requests needing more medical information, reviewers would identify what is needed within the applicable deadline. The clock would restart when the information arrives. The deadline would run from receipt of an exception request or filing of an appeal.

Insurers and coverage reviewers would use research-based medical guidance for try-first drug rules and obtain Montana's insurance commissioner's approval before changing those rules or their medical review criteria. These standards would govern required drug sequences in covered state-regulated plans. Expert-panel guidance would recommend the required drug order, manage conflicts of interest, allow public review, consider different patient needs, and receive continuing updates. When no expert panel exists, publications reviewed by other experts could serve as guidance. No new organization would have to be formed. Insurers and coverage reviewers would certify compliance to the insurance commissioner annually and report requests, decisions, appeals, and specified medical reasons to the state auditor each year.