House Bill 1143

AN ACT TO PROHIBIT HEALTH BENEFIT PLANS FROM REQUIRING STEP THERAPY OR FAIL-FIRST PROTOCOLS BEFORE THE PLAN PROVIDES COVERAGE OF CERTAIN PRESCRIPTION DRUGS TO TREAT ADVANCED, METASTATIC CANCER AND ASSOCIATED CONDITIONS; TO AMEND SECTION 83-9-36, MISSISSIPPI CODE OF 1972, TO CONFORM TO THE PRECEDING PROVISIONS; AND FOR RELATED PURPOSES.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:

SECTION 1. (1) As used in this section, the following terms shall be defined as provided in this subsection:

(a) "Associated conditions" means the symptoms or side effects associated with advanced, metastatic cancer or its treatment and which, in the judgment of the health care practitioner, further jeopardizes the health of a patient if left untreated.

(b) "Advanced, metastatic cancer" means cancer that has spread from the primary or original site of the cancer to nearby tissues, lymph nodes, or other areas or parts of the body.

(c) "Health benefit plan" means a policy, contract, certificate or agreement entered into, offered by or issued by an insurer to provide, deliver, arrange for, pay for or reimburse any of the costs of health care services.

(2) A health benefit plan that provides coverage for advanced, metastatic cancer and associated conditions may not require, before the health benefit plan provides coverage of a prescription drug approved by the United States Food and Drug Administration, that the enrollee:

(a) Fail to successfully respond to a different drug; or

(b) Prove a history of failure of a different drug.

(3) This section applies only to a drug the use of which is:

(a) Consistent with best practices for the treatment of advanced, metastatic cancer or an associated condition;

(b) Supported by peer-reviewed, evidence-based literature; and

SECTION 2. Section 83-9-36, Mississippi Code of 1972, is amended as follows:

83-9-36. (1) When medications for the treatment of any medical condition are restricted for use by an insurer by a step therapy or fail-first protocol, the prescribing practitioner shall have access to a clear and convenient process to expeditiously request an override of that restriction from the insurer. An override of that restriction shall be expeditiously granted by the insurer under the following circumstances:

(a) The prescribing practitioner can demonstrate, based on sound clinical evidence, that the preferred treatment required under step therapy or fail-first protocol has been ineffective in the treatment of the insured's disease or medical condition; or

(b) Based on sound clinical evidence or medical and scientific evidence:

(i) The prescribing practitioner can demonstrate that the preferred treatment required under the step therapy or fail-first protocol is expected or likely to be ineffective based on the known relevant physical or mental characteristics of the insured and known characteristics of the drug regimen; or

(ii) The prescribing practitioner can demonstrate that the preferred treatment required under the step therapy or fail-first protocol will cause or will likely cause an adverse reaction or other physical harm to the insured.

(2) The duration of any step therapy or fail-first protocol shall not be longer than a period of thirty (30) days when the treatment is deemed clinically ineffective by the prescribing practitioner. When the prescribing practitioner can demonstrate, through sound clinical evidence, that the originally prescribed medication is likely to require more than thirty (30) days to provide any relief or an amelioration to the insured, the step therapy or fail-first protocol may be extended up to seven (7) additional days.

(3) As used in this section:

(a) "Insurer" means any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract or agreement with a health maintenance organization or a preferred provider organization, health and accident insurance policy, or any other insurance contract of this type, including a group insurance plan. However, the term "insurer" does not include a preferred provider organization that is only a network of providers and does not define health care benefits for the purpose of coverage under a health care benefits plan.

(b) "Practitioner" has the same meaning as defined in Section 73-21-73.

(4) The provisions of Section 1 of this act shall supersede the provisions of this section to the extent of any conflict between Section 1 and this section.

SECTION 3. This act shall take effect and be in force from and after July 1, 2024.