SECTION 1. Chapter 118E of the General Laws is hereby amended by inserting after section 10J the following section:-
Section 10K. The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract with state Medicaid (MassHealth) shall establish a step therapy program for prescription medications for the treatment of epilepsy and seizure disorders. Said program may condition coverage and payment for epilepsy and seizure disorder medication on a requirement that the patient try and fail on not more than one other prescription medication prior to the prescribed medication being authorized.
Further, said program shall require that the prescribing practitioners, when medications are restricted, have access to a clear and convenient process to request an override of such restriction from the division or its contracted agents. The division or its contracted agents shall expeditiously grant an override of such restriction whenever the prescribing practitioner demonstrates that:
1. The preferred treatment required under step therapy has been ineffective in the treatment of the patients’ medical condition in the past;
2. the drug regimen required under the step therapy program is expected to be ineffective based on the known relevant physical and mental characteristics of the patient and the known characteristics of the drug regimen;
3. the preferred treatment required under the step therapy program will cause or will likely cause an adverse reaction or other physical harm to the patient; or
4. it is in the best interest of the patient to provide the recommended drug regime based on medical necessity.
The duration of this step therapy program requirement shall not be longer that a period of thirty days, after which the prescribing practitioner may deem such treatment as clinically ineffective for the patient. When the prescribing practitioner deems the treatment to be clinically ineffective, the drug prescribed and recommended by the practitioner shall be dispensed and covered by the division and its contracted agents.
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