Nevada Revised Statutes 695C.16947 – Plan covering prescription drugs: Submission to step therapy for drug to treat psychiatric condition prohibited in certain circumstances
1. A health care plan which provides coverage for prescription drugs must not require an enrollee to submit to a step therapy protocol before covering a drug approved by the Food and Drug Administration that is prescribed to treat a psychiatric condition of the enrollee, if:
Terms Used In Nevada Revised Statutes 695C.16947
- Contract: A legal written agreement that becomes binding when signed.
- Enrollee: means a natural person who has been voluntarily enrolled in a health care plan. See Nevada Revised Statutes 695C.030
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Health care plan: means any arrangement whereby any person undertakes to provide, arrange for, pay for or reimburse any part of the cost of any health care services and at least part of the arrangement consists of arranging for or the provision of health care services paid for by or on behalf of the enrollee on a periodic prepaid basis. See Nevada Revised Statutes 695C.030
- Health maintenance organization: means any person which provides or arranges for provision of a health care service or services and is responsible for the availability and accessibility of such service or services to its enrollees, which services are paid for or on behalf of the enrollees on a periodic prepaid basis without regard to the dates health services are rendered and without regard to the extent of services actually furnished to the enrollees, except that supplementing the fixed prepayments by nominal additional payments for services in accordance with regulations adopted by the Commissioner shall not be deemed to render the arrangement not to be on a prepaid basis. See Nevada Revised Statutes 695C.030
- physician: means a person who engages in the practice of medicine, including osteopathy and homeopathy. See Nevada Revised Statutes 0.040
- Provider: means any physician, hospital or other person who is licensed or otherwise authorized in this state to furnish health care services. See Nevada Revised Statutes 695C.030
(a) The drug has been approved by the Food and Drug Administration with indications for the psychiatric condition of the enrollee or the use of the drug to treat that psychiatric condition is otherwise supported by medical or scientific evidence;
(b) The drug is prescribed by:
(1) A psychiatrist;
(2) A physician assistant under the supervision of a psychiatrist;
(3) An advanced practice registered nurse who has the psychiatric training and experience prescribed by the State Board of Nursing pursuant to NRS 632.120; or
(4) A primary care provider that is providing care to an enrollee in consultation with a practitioner listed in subparagraph (1), (2) or (3), if the closest practitioner listed in subparagraph (1), (2) or (3) who participates in the network plan of the health maintenance organization is located 60 miles or more from the residence of the enrollee; and
(c) The practitioner listed in paragraph (b) who prescribed the drug knows, based on the medical history of the enrollee, or reasonably expects each alternative drug that is required to be used earlier in the step therapy protocol to be ineffective at treating the psychiatric condition.
2. Any provision of a health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after July 1, 2023, which is in conflict with this section is void.
3. As used in this section:
(a) ’Medical or scientific evidence’ has the meaning ascribed to it in NRS 695G.053.
(b) ’Network plan’ means a health care plan offered by a health maintenance organization under which the financing and delivery of medical care is provided, in whole or in part, through a defined set of providers under contract with the health maintenance organization. The term does not include an arrangement for the financing of premiums.
(c) ’Step therapy protocol’ means a procedure that requires an enrollee to use a prescription drug or sequence of prescription drugs other than a drug that a practitioner recommends for treatment of a psychiatric condition of the enrollee before his or her health care plan provides coverage for the recommended drug.