2023 Nevada Revised Statutes › Chapter 695A - Fraternal Benefit Societies › NRS 695A.259 - Benefit contract covering prescription drug for treatment of cancer or cancer symptom that is part of step therapy protocol: Society required to allow insured or attending practitioner to apply for exemption from step therapy protocol in certain circumstances; procedure for applying for and granting exemption.

1. A society that offers or issues a benefit contract which provides coverage of a prescription drug for the treatment of cancer or any symptom of cancer that is part of a step therapy protocol shall allow an insured who has been diagnosed with stage 3 or 4 cancer or the attending practitioner of the insured to apply for an exemption from the step therapy protocol. The application process for such an exemption must:
(a) Allow the insured or attending practitioner, or a designated advocate for the insured or attending practitioner, to present to the society the clinical rationale for the exemption and any relevant medical information.
(b) Clearly prescribe the information and supporting documentation that must be submitted with the application, the criteria that will be used to evaluate the request and the conditions under which an expedited determination pursuant to subsection 4 is warranted.
(c) Require the review of each application by at least one physician, registered nurse or pharmacist.
2. The information and supporting documentation required pursuant to paragraph (b) of subsection 1:
(a) May include, without limitation:
(1) The medical history or other health records of the insured demonstrating that the insured has:
(I) Tried other drugs included in the pharmacological class of drugs for which the exemption is requested without success; or
(II) Taken the requested drug for a clinically appropriate amount of time to establish stability in relation to the cancer and the guidelines of the prescribing practitioner; and
(2) Any other relevant clinical information.
(b) Must not include any information or supporting documentation that is not necessary to make a determination about the application.
3. Except as otherwise provided in subsection 4, a society that receives an application for an exemption pursuant to subsection 1 shall:
(a) Make a determination concerning the application if the application is complete or request additional information or documentation necessary to complete the application not later than 72 hours after receiving the application; and
(b) If it requests additional information or documentation, make a determination concerning the application not later than 72 hours after receiving the requested information or documentation.
4. If, in the opinion of the attending practitioner, a step therapy protocol may seriously jeopardize the life or health of the insured, a society that receives an application for an exemption pursuant to subsection 1 must make a determination concerning the application as expeditiously as necessary to avoid serious jeopardy to the life or health of the insured.
5. A society shall disclose to the insured or attending practitioner who submits an application for an exemption from a step therapy protocol pursuant to subsection 1 the qualifications of each person who will review the application.
6. A society must grant an exemption from a step therapy protocol in response to an application submitted pursuant to subsection 1 if:
(a) Any treatment otherwise required under the step therapy or any drug in the same pharmacological class or having the same mechanism of action as the drug for which the exemption is requested has not been effective at treating the cancer or symptom of the insured when prescribed in accordance with clinical indications, clinical guidelines or other peer-reviewed evidence;
(b) Delay of effective treatment would have severe or irreversible consequences for the insured and the treatment otherwise required under the step therapy is not reasonably expected to be effective based on the physical or mental characteristics of the insured and the known characteristics of the treatment;
(c) Each treatment otherwise required under the step therapy:
(1) Is contraindicated for the insured or has caused or is likely, based on peer-reviewed clinical evidence, to cause an adverse reaction or other physical harm to the insured; or
(2) Has prevented or is likely to prevent the insured from performing the responsibilities of his or her occupation or engaging in activities of daily living, as defined in 42 C.F.R. § 441.505;
(d) The condition of the insured is stable while being treated with the prescription drug for which the exemption is requested and the insured has previously received approval for coverage of that drug; or
(e) Any other condition for which such an exemption is required by regulation of the Commissioner is met.
7. If a society approves an application for an exemption from a step therapy protocol pursuant to this section, the society must cover the prescription drug to which the exemption applies in accordance with the terms of the applicable benefit contract. The society may initially limit the coverage to a 1-week supply of the drug for which the exemption is granted. If the attending practitioner determines after 1 week that the drug is effective at treating the cancer or symptom for which it was prescribed, the society must continue to cover the drug for as long as it is necessary to treat the insured for the cancer or symptom. The society may conduct a review not more frequently than once each quarter to determine, in accordance with available medical evidence, whether the drug remains necessary to treat the insured for the cancer or symptom. The society shall provide a report of the review to the insured.
8. A society shall post in an easily accessible location on an Internet website maintained by the society a form for requesting an exemption pursuant to this section.
9. A benefit contract subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after January 1, 2022, has the legal effect of including the coverage required by this section, and any provision of the benefit contract that conflicts with this section is void.
10. As used in this section, "attending practitioner" means the practitioner, as defined in NRS 639.0125, who has primary responsibility for the treatment of the cancer or any symptom of such cancer of an insured.
(Added to NRS by 2021, 2665)