{ "_meta": { "name": "State law cited in AppealArmor appeal letters", "source": "AppealArmor data/core/state-law.json, the table the letter writer reads. Every row quotes one provision from the official source in its url. All rows are on file; the letter can quote only the rows whose letterUse is not next_steps_only.", "page": "https://appealarmor.com/states/", "generatedAt": "2026-10-26T05:56:03.034Z", "rowCount": 98, "rowsTheLetterCanQuote": 92, "rowsOnNextStepsSheetOnly": 6, "jurisdictionsWithRows": 51, "jurisdictionsWhereTheLetterCanQuote": 49, "jurisdictionsWithoutRows": [], "topics": [ "external_review", "step_therapy" ], "license": "The quoted provisions are statutes and regulations, which are public law, quoted from the official source in each row. This file is provided for reference and is not legal advice; check the source for the current text.", "howRowsAreChosen": "A row is quoted in a letter only for an individual plan or an employer plan confirmed fully insured (never Medicare, Medicaid or a self-funded employer plan), only when appliesTo includes the plan type, a step_therapy row only when the confirmed denial reason is about step therapy, and a row with a condition only when letterUse allows it. letterUse: \"letter\" = quoted when plan and topic match; \"letter_when_denial_matches\" = also needs the confirmed denial reason, diagnosis or treatment to mention a gate word; \"next_steps_only\" = never quoted in the letter, listed on the Next Steps sheet with its condition." }, "rows": [ { "id": "ak-external_review", "state": "AK", "stateName": "Alaska", "topic": "external_review", "title": "Request for external review", "cite": "3 AAC 28.954(a)", "quote": "A covered person or the covered person's authorized representative may make a request to the director for an external review of an adverse determination or a final adverse determination.", "url": "https://www.akleg.gov/basis/aac.asp?media=print&secStart=3.28.954&secEnd=3.28.954", "appliesTo": [ "individual", "employer_private" ], "condition": "if your plan is a fully insured health plan issued in Alaska (not a self-funded employer plan, Medicare or Medicaid)", "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "ak-step_therapy", "state": "AK", "stateName": "Alaska", "topic": "step_therapy", "title": "Reviews of grievances involving an adverse determination", "cite": "3 AAC 28.936(a)", "quote": "A covered person or the covered person's authorized representative may file a grievance with a health care insurer requesting a review of an adverse determination.", "url": "https://www.akleg.gov/basis/aac.asp?media=print&secStart=3.28.936&secEnd=3.28.936", "appliesTo": [ "individual", "employer_private" ], "condition": "if your plan is a fully insured health plan issued in Alaska", "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "al-step_therapy", "state": "AL", "stateName": "Alabama", "topic": "step_therapy", "title": "Standards for Utilization Review Agents", "cite": "Ala. Code § 27-3A-5(a)(4)", "quote": "Utilization review agents shall maintain and make available a written description of the appeal procedure by which the enrollee or the provider of record may seek review of a determination by the utilization review agent.", "url": "https://alison.legislature.state.al.us/code-of-alabama?section=27-3A-5", "appliesTo": [ "individual", "employer_private" ], "condition": "if the denial was made by a utilization review agent covered by the Alabama Health Care Service Utilization Review Act (agents accredited by URAC are exempt, 27-3A-5(b))", "letterUse": "next_steps_only", "retrievedAt": "2026-10-15T11:29:35.008Z" }, { "id": "ar-external_review", "state": "AR", "stateName": "Arkansas", "topic": "external_review", "title": "Rule 76, Arkansas External Review Rule: request for external review", "cite": "23 CAR § 117-105(b)", "quote": "A covered person or the covered person’s authorized representative may make a request for an external review of an adverse determination or final adverse determination.", "url": "https://codeofarrules.arkansas.gov/Rules/Rule?levelType=section&titleID=23&chapterID=39&subChapterID=51&partID=854&subPartID=5826§ionID=38002", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:28:27.235Z" }, { "id": "ar-step_therapy", "state": "AR", "stateName": "Arkansas", "topic": "step_therapy", "title": "Step therapy protocol exceptions (Act 97 of 2021, section 23-79-2104)", "cite": "Ark. Code § 23-79-2104(b)", "quote": "A step therapy protocol exception shall be expeditiously granted if:", "url": "https://arkleg.state.ar.us/Home/FTPDocument?path=%2FACTS%2F2021R%2FPublic%2FACT97.pdf", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:28:27.235Z" }, { "id": "az-external_review", "state": "AZ", "stateName": "Arizona", "topic": "external_review", "title": "External independent review", "cite": "Ariz. Rev. Stat. § 20-2537(A)", "quote": "If the utilization review agent denies the member's request for a covered service or claim for a covered service at all applicable internal levels of review or if the member has exhausted the health care insurer's internal levels of review pursuant to section 20-2533, subsection F, the member may initiate an external independent review.", "url": "https://www.azleg.gov/ars/20/02537.htm", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:18:37.666Z" }, { "id": "az-step_therapy", "state": "AZ", "stateName": "Arizona", "topic": "step_therapy", "title": "Step therapy exception requests", "cite": "Ariz. Rev. Stat. § 20-3654(B)", "quote": "A step therapy exception request shall be granted if sufficient justification and any necessary supporting clinical documentation are submitted to establish that any of the following applies:", "url": "https://www.azleg.gov/ars/20/03654.htm", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:18:37.666Z" }, { "id": "ca-external_review", "state": "CA", "stateName": "California", "topic": "external_review", "title": "Independent Medical Review System", "cite": "Cal. Health & Safety Code § 1374.30(e)", "quote": "Every health care service plan contract that is issued, amended, renewed, or delivered in this state on or after January 1, 2000, shall provide an enrollee with the opportunity to seek an independent medical review whenever health care services have been denied, modified, or delayed by the plan, or by one of its contracting providers, if the decision was based in whole or in part on a finding that the proposed health care services are not medically necessary.", "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC§ionNum=1374.30", "appliesTo": [ "individual", "employer_private" ], "condition": "if your plan is regulated by the California Department of Managed Health Care", "letterUse": "next_steps_only", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "ca-step_therapy", "state": "CA", "stateName": "California", "topic": "step_therapy", "title": "Step therapy exception requests", "cite": "Cal. Health & Safety Code § 1367.206(b)", "quote": "A health care service plan shall expeditiously grant a request for a step therapy exception within the applicable time limit required by Section 1367.241 if a prescribing provider submits necessary justification and supporting clinical documentation supporting the provider’s determination that the required prescription drug is inconsistent with good professional practice for provision of medically necessary covered services to the enrollee, taking into consideration the enrollee’s needs and medical history, along with the professional judgment of the enrollee’s provider.", "url": "https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC§ionNum=1367.206", "appliesTo": [ "individual", "employer_private" ], "condition": "if your plan is regulated by the California Department of Managed Health Care", "letterUse": "next_steps_only", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "co-external_review", "state": "CO", "stateName": "Colorado", "topic": "external_review", "title": "Independent external review of adverse determinations", "cite": "Colo. Rev. Stat. § 10-16-113.5(3)", "quote": "Carriers shall make available an independent external review process that meets the requirements of this section.", "url": "https://leg.colorado.gov/sites/default/files/images/olls/crs2024-title-10.pdf", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:35:27.802Z" }, { "id": "co-step_therapy", "state": "CO", "stateName": "Colorado", "topic": "step_therapy", "title": "Step therapy: limitations, exceptions", "cite": "Colo. Rev. Stat. § 10-16-145(4)(a)", "quote": "A carrier, a private utilization review organization, or a PBM shall grant an exception to step therapy if the prescribing provider submits justification and supporting clinical documentation, if needed, that states:", "url": "https://leg.colorado.gov/sites/default/files/images/olls/crs2024-title-10.pdf", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:35:27.802Z" }, { "id": "ct-external_review", "state": "CT", "stateName": "Connecticut", "topic": "external_review", "title": "External reviews and expedited external reviews", "cite": "Conn. Gen. Stat. § 38a-591g(a)(1)", "quote": "A covered person or a covered person's authorized representative may file a request for an external review or an expedited external review of an adverse determination or a final adverse determination in accordance with the provisions of this section.", "url": "https://www.cga.ct.gov/current/pub/chap_700c.htm", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:16:38.140Z" }, { "id": "ct-step_therapy", "state": "CT", "stateName": "Connecticut", "topic": "step_therapy", "title": "Prescription drug coverage; step therapy use", "cite": "Conn. Gen. Stat. § 38a-510(b)(1)", "quote": "each insurance company, hospital service corporation, medical service corporation, health care center or other entity that uses step therapy for such prescription drugs shall establish and disclose to its health care providers a process by which an insured's treating health care provider may request at any time an override of the use of any step therapy drug regimen.", "url": "https://www.cga.ct.gov/current/pub/chap_700c.htm", "appliesTo": [ "individual" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:16:38.140Z" }, { "id": "dc-external_review", "state": "DC", "stateName": "District of Columbia", "topic": "external_review", "title": "External appeals process for matters other than rescissions", "cite": "D.C. Code § 44-301.07(a)", "quote": "The Director shall establish and maintain an external appeals process whereby a member or member representative who is dissatisfied with a decision rendered in an internal appeals process shall have the opportunity to pursue an external appeal before an independent review organization.", "url": "https://code.dccouncil.gov/us/dc/council/code/sections/44-301.07", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:29:35.008Z" }, { "id": "dc-step_therapy", "state": "DC", "stateName": "District of Columbia", "topic": "step_therapy", "title": "Appeals (Prior Authorization by a Utilization Review Entity)", "cite": "D.C. Code § 31-3875.05(b)", "quote": "In reviewing an appeal, the utilization review entity shall consider all known clinical aspects of the health care service under review, including a review of all pertinent medical records, other relevant records, and any medical literature provided by the enrollee, representative, or the enrollee's health care provider.", "url": "https://code.dccouncil.gov/us/dc/council/code/sections/31-3875.05", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:29:35.008Z" }, { "id": "de-external_review", "state": "DE", "stateName": "Delaware", "topic": "external_review", "title": "Independent health care appeals program", "cite": "18 Del. C. § 6416(c)", "quote": "A covered person may apply to the Independent Health Appeals Program for a review of any decision to deny, reduce or terminate covered benefits if the person has already completed the carrier’s internal appeals process and the person contests the final decision by a carrier.", "url": "https://delcode.delaware.gov/title18/c064/index.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "de-step_therapy", "state": "DE", "stateName": "Delaware", "topic": "step_therapy", "title": "Step therapy exception process", "cite": "18 Del. C. § 3381(a)", "quote": "A step therapy exception determination shall be expeditiously granted in any one of the following circumstances:", "url": "https://delcode.delaware.gov/title18/c033/sc02/index.html", "appliesTo": [ "individual" ], "condition": "if your plan is an individual health insurance contract (Chapter 33); group plans fall under the counterpart 18 Del. C. § 3591", "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "fl-step_therapy", "state": "FL", "stateName": "Florida", "topic": "step_therapy", "title": "Step-therapy protocol", "cite": "Fla. Stat. § 627.42393(3)(b)", "quote": "A denial of a protocol exemption request must include a written explanation of the reason for the denial, the clinical rationale that supports the denial, and the procedure for appealing the health insurer’s denial.", "url": "https://www.flsenate.gov/Laws/Statutes/2025/627.42393", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:23:39.887Z" }, { "id": "ga-external_review", "state": "GA", "stateName": "Georgia", "topic": "external_review", "title": "Patient's Right to Independent Review: Request for Independent Review (Georgia Insurance Commissioner rule implementing O.C.G.A. § 33-20A-30 et seq.)", "cite": "Ga. Comp. R. & Regs. r. 120-2-111-.04(1)", "quote": "An eligible enrollee shall be entitled to appeal to an independent review organization when:", "url": "https://rules.sos.ga.gov/gac/120-2-111-.04", "appliesTo": [ "individual", "employer_private" ], "condition": "if your plan is a Georgia managed care plan (insurer, HMO or similar managed care entity) and you have finished the plan's internal grievance procedure", "letterUse": "next_steps_only", "retrievedAt": "2026-10-15T11:23:39.887Z" }, { "id": "ga-step_therapy", "state": "GA", "stateName": "Georgia", "topic": "step_therapy", "title": "Step therapy protocols; exceptions (HB 63, 2019)", "cite": "O.C.G.A. § 33-24-59.25(b)", "quote": "A step therapy exception shall be granted by a health benefit plan if the prescribing provider's submitted justification and supporting clinical documentation, if needed, is completed and determined to support such provider's statement that:", "url": "https://gov.georgia.gov/document/signed-legislation/hb-63pdf/download", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "hi-external_review", "state": "HI", "stateName": "Hawaii", "topic": "external_review", "title": "Standard external review", "cite": "Haw. Rev. Stat. § 432E-34(a)", "quote": "An enrollee or the enrollee's appointed representative may file a request for an external review with the commissioner within one hundred thirty days of receipt of notice of an adverse action.", "url": "https://www.capitol.hawaii.gov/hrscurrent/Vol09_Ch0431-0435H/HRS0432E/HRS_0432E-0034.htm", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:29:35.008Z" }, { "id": "hi-step_therapy", "state": "HI", "stateName": "Hawaii", "topic": "step_therapy", "title": "Complaints and appeals procedure for enrollees", "cite": "Haw. Rev. Stat. § 432E-5(a)", "quote": "A health carrier with enrollees in this State shall establish and maintain a procedure to provide for the resolution of an enrollee's complaints and internal appeals.", "url": "https://www.capitol.hawaii.gov/hrscurrent/Vol09_Ch0431-0435H/HRS0432E/HRS_0432E-0005.htm", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:29:35.008Z" }, { "id": "ia-external_review", "state": "IA", "stateName": "Iowa", "topic": "external_review", "title": "Request for external review", "cite": "Iowa Code § 514J.105", "quote": "A covered person or the covered person’s authorized representative may make a request for an external review of a final adverse determination.", "url": "https://www.legis.iowa.gov/docs/code/514J.105.pdf", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-26T05:56:03.034Z" }, { "id": "ia-step_therapy", "state": "IA", "stateName": "Iowa", "topic": "step_therapy", "title": "Use of step therapy protocols", "cite": "Iowa Code § 514F.7(3)(b)", "quote": "A step therapy override exception shall be approved by a health carrier, health benefit plan, or utilization review organization if any of the following circumstances apply:", "url": "https://www.legis.iowa.gov/docs/code/514F.7.pdf", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-26T05:56:03.034Z" }, { "id": "id-external_review", "state": "ID", "stateName": "Idaho", "topic": "external_review", "title": "Standard external review", "cite": "Idaho Code § 41-5908(1)", "quote": "Within four (4) months after the date of issuance of a notice of a final adverse benefit determination pursuant to section 41-5905, Idaho Code, a covered person may file a request for an external review with the director.", "url": "https://legislature.idaho.gov/statutesrules/idstat/Title41/T41CH59/SECT41-5908/", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:29:35.008Z" }, { "id": "id-step_therapy", "state": "ID", "stateName": "Idaho", "topic": "step_therapy", "title": "Grievance system (Idaho Managed Care Reform Act)", "cite": "Idaho Code § 41-3918(1)", "quote": "The system shall provide reasonable procedures for the resolution of grievances, and shall include an appeals process which affords the member the right to a prompt review by a grievance panel before whom the member has the right either to appear or be heard, or both.", "url": "https://legislature.idaho.gov/statutesrules/idstat/Title41/T41CH39/SECT41-3918/", "appliesTo": [ "individual", "employer_private" ], "condition": "if your plan is an HMO or other managed care plan certified under Idaho Code chapter 39", "letterUse": "next_steps_only", "retrievedAt": "2026-10-15T11:29:35.008Z" }, { "id": "il-external_review", "state": "IL", "stateName": "Illinois", "topic": "external_review", "title": "Request for external review", "cite": "215 Ill. Comp. Stat. 180/25", "quote": "A covered person or the covered person's authorized representative may make a request for a standard external or expedited external review of an adverse determination or final adverse determination.", "url": "https://ilga.gov/Documents/legislation/ilcs/documents/021501800K25.htm", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:31:50.040Z" }, { "id": "il-step_therapy", "state": "IL", "stateName": "Illinois", "topic": "step_therapy", "title": "Medical necessity determinations; step therapy prohibited", "cite": "215 Ill. Comp. Stat. 134/87(f)", "quote": "Beginning January 1, 2026, no utilization review program or any policy, contract, certificate, evidence of coverage, or formulary shall impose step therapy requirements.", "url": "https://ilga.gov/Documents/legislation/ilcs/documents/021501340K87.htm", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:31:50.040Z" }, { "id": "in-external_review", "state": "IN", "stateName": "Indiana", "topic": "external_review", "title": "Insurer to establish external grievance procedures", "cite": "Ind. Code § 27-8-29-12", "quote": "An insurer shall establish and maintain an external grievance procedure for the resolution of external grievances regarding the following:", "url": "https://iga.in.gov/ic/2025/Title_27.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:16:38.140Z" }, { "id": "in-step_therapy", "state": "IN", "stateName": "Indiana", "topic": "step_therapy", "title": "Step therapy protocol", "cite": "Ind. Code § 27-8-5-30(h)(3)", "quote": "That a protocol exception will be granted if any of the following apply:", "url": "https://iga.in.gov/ic/2025/Title_27.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:16:38.140Z" }, { "id": "ks-external_review", "state": "KS", "stateName": "Kansas", "topic": "external_review", "title": "External review procedure", "cite": "Kan. Stat. Ann. § 40-22a14(d)(1)", "quote": "The insured has the right to request an independent external review of an adverse decision by a health insurance plan or insurer when:", "url": "https://www.ksrevisor.org/statutes/chapters/ch40/040_022a_0014.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:16:38.140Z" }, { "id": "ky-external_review", "state": "KY", "stateName": "Kentucky", "topic": "external_review", "title": "External review of adverse benefit determination", "cite": "Ky. Rev. Stat. Ann. § 304.17A-623(2)", "quote": "A covered person, an authorized person, or a provider acting on behalf of and with the consent of the covered person, may request an external review of an adverse benefit determination, other than a coverage denial, rendered by an insurer, its designee, or agent.", "url": "https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=57346", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:29:13.924Z" }, { "id": "ky-step_therapy", "state": "KY", "stateName": "Kentucky", "topic": "step_therapy", "title": "Step therapy protocols", "cite": "Ky. Rev. Stat. Ann. § 304.17A-163(3)(a)", "quote": "When coverage of a prescription drug for the treatment of any medical condition is restricted for use by an insurer, health plan, private review agent, or a pharmacy benefit manager by a step therapy protocol, the insured and prescribing provider shall have access to a clear, readily accessible, and convenient process to request a step therapy exception.", "url": "https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=54758", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:29:13.924Z" }, { "id": "la-external_review", "state": "LA", "stateName": "Louisiana", "topic": "external_review", "title": "Request for external review", "cite": "La. Rev. Stat. Ann. § 22:2434(B)", "quote": "A covered person or his authorized representative may make a request for an external review of an adverse determination or final adverse determination when such determination involves an issue of medical necessity, appropriateness, health care setting, level of care, effectiveness, or a rescission.", "url": "https://legis.la.gov/Legis/Law.aspx?d=860846", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:27:37.734Z" }, { "id": "la-step_therapy", "state": "LA", "stateName": "Louisiana", "topic": "step_therapy", "title": "Step therapy or fail first protocol override", "cite": "La. Rev. Stat. Ann. § 22:1053(E)", "quote": "Denial of a step therapy or fail first protocol override request shall not be considered a final adverse determination and shall be eligible for an appeal of coverage determination pursuant to R.S. 22:2401.", "url": "https://legis.la.gov/Legis/Law.aspx?d=727112", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:27:37.734Z" }, { "id": "ma-external_review", "state": "MA", "stateName": "Massachusetts", "topic": "external_review", "title": "External review process", "cite": "Mass. Gen. Laws ch. 176O, § 14(a)", "quote": "An insured who remains aggrieved by an adverse determination and has exhausted all remedies available from the formal internal grievance process required pursuant to section 13, may seek further review of the grievance by a review panel established by the office of patient protection", "url": "https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter176O/Section14", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:31:50.040Z" }, { "id": "ma-step_therapy", "state": "MA", "stateName": "Massachusetts", "topic": "step_therapy", "title": "Step therapy protocol: prescription drugs", "cite": "Mass. Gen. Laws ch. 176O, § 12A(c)(1)", "quote": "If coverage of a prescription drug for the treatment of any medical condition is restricted for use by a carrier directly or through a utilization review organization through the use of a step therapy protocol, the insured and prescribing health care provider shall have access to a clear, readily accessible and convenient process to request an exception to such step therapy protocol.", "url": "https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter176O/Section12A", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:31:50.040Z" }, { "id": "md-external_review", "state": "MD", "stateName": "Maryland", "topic": "external_review", "title": "Complaint to the Commissioner", "cite": "Md. Code Ann., Ins. § 15-10A-03(a)(1)", "quote": "Within 4 months after the date of receipt of an adverse decision or a grievance decision, a member, a member’s representative, or a health care provider, who filed the grievance on behalf of the member under § 15–10A–02(b)(2)(iii) of this subtitle, may file a complaint with the Commissioner.", "url": "https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gin§ion=15-10A-03&enactments=false", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:16:38.140Z" }, { "id": "md-step_therapy", "state": "MD", "stateName": "Maryland", "topic": "step_therapy", "title": "Step therapy or fail-first protocol", "cite": "Md. Code Ann., Ins. § 15-142(f)(2)", "quote": "A step therapy exception request shall be granted if, based on the professional judgment of the prescriber and any information and documentation required under paragraph (1)(i) of this subsection:", "url": "https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gin§ion=15-142&enactments=false", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:16:38.140Z" }, { "id": "me-external_review", "state": "ME", "stateName": "Maine", "topic": "external_review", "title": "Independent external review", "cite": "Me. Rev. Stat. tit. 24-A, § 4312", "quote": "An enrollee or the enrollee's authorized representative has the right to an independent external review of a carrier's adverse health care treatment decision made by or on behalf of a carrier offering or renewing a health plan in accordance with the requirements of this section.", "url": "https://legislature.maine.gov/statutes/24-A/title24-Asec4312.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:18:37.666Z" }, { "id": "me-step_therapy", "state": "ME", "stateName": "Maine", "topic": "step_therapy", "title": "Step therapy: exceptions process", "cite": "Me. Rev. Stat. tit. 24-A, § 4320-N(6)", "quote": "When coverage of a prescription drug for the treatment of any medical condition is restricted for use by a carrier or utilization review organization through the use of a step therapy protocol, the enrollee and prescriber must have access to a clear, readily accessible and convenient process to request a step therapy override exception determination from that carrier or utilization review organization.", "url": "https://legislature.maine.gov/statutes/24-A/title24-Asec4320-N.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:18:37.666Z" }, { "id": "mi-external_review", "state": "MI", "stateName": "Michigan", "topic": "external_review", "title": "Request for external review", "cite": "Mich. Comp. Laws § 550.1911(1)", "quote": "a covered person or the covered person's authorized representative may file a request for an external review with the director.", "url": "https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-550-1911", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:23:39.887Z" }, { "id": "mi-step_therapy", "state": "MI", "stateName": "Michigan", "topic": "step_therapy", "title": "Insurer providing prescription drug coverage; formulary restrictions; expedited review of coverage for nonformulary alternative", "cite": "Mich. Comp. Laws § 500.3406o(1)(c)", "quote": "Provide for exceptions from the formulary limitation when a nonformulary alternative is a medically necessary and appropriate alternative.", "url": "https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-500-3406o", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:23:39.887Z" }, { "id": "mn-external_review", "state": "MN", "stateName": "Minnesota", "topic": "external_review", "title": "External review of adverse determinations", "cite": "Minn. Stat. § 62Q.73, subd. 3(a)", "quote": "Any enrollee or anyone acting on behalf of an enrollee who has received an adverse determination may submit a written request for an external review of the adverse determination", "url": "https://www.revisor.mn.gov/statutes/cite/62Q.73", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:14:16.299Z" }, { "id": "mn-step_therapy", "state": "MN", "stateName": "Minnesota", "topic": "step_therapy", "title": "Step therapy override", "cite": "Minn. Stat. § 62Q.184, subd. 3(a)", "quote": "When coverage of a prescription drug for the treatment of a medical condition is restricted for use by a health plan company through the use of a step therapy protocol, enrollees and prescribing health care providers shall have access to a clear, readily accessible, and convenient process to request a step therapy override.", "url": "https://www.revisor.mn.gov/statutes/cite/62Q.184", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:14:16.299Z" }, { "id": "mo-external_review", "state": "MO", "stateName": "Missouri", "topic": "external_review", "title": "Appeals of grievances determined by the director", "cite": "Mo. Rev. Stat. § 376.1387(1)", "quote": "The director shall resolve any grievance regarding an adverse determination as to covered services appealed by an enrollee or health carrier or plan sponsor through any means not specifically prohibited by law but if the grievance is unresolved by the director then it shall be resolved by referral of such grievance to an independent review organization.", "url": "https://revisor.mo.gov/main/OneSection.aspx?section=376.1387", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:16:38.140Z" }, { "id": "mo-step_therapy", "state": "MO", "stateName": "Missouri", "topic": "step_therapy", "title": "Restriction on step therapy protocol; override exception", "cite": "Mo. Rev. Stat. § 376.2034(2)", "quote": "A step therapy override exception determination shall be granted if the patient has tried the step therapy required prescription drugs while under his or her current or previous health insurance or health benefit plan, and such prescription drugs were discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event, or if the patient's treating health care provider attests that coverage of the prescribed prescription drug is necessary to save the life of the patient.", "url": "https://revisor.mo.gov/main/OneSection.aspx?section=376.2034", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:16:38.140Z" }, { "id": "ms-external_review", "state": "MS", "stateName": "Mississippi", "topic": "external_review", "title": "Mississippi Health Carrier External Review Regulation, Request for External Review", "cite": "19 Miss. Admin. Code Pt. 3, R. 15.05(B)", "quote": "A covered person or the covered person’s authorized representative may make a request for an external review of an adverse determination or final adverse determination.", "url": "https://www.mid.ms.gov/wp-content/uploads/2023/04/20113creg.pdf", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:23:39.887Z" }, { "id": "ms-step_therapy", "state": "MS", "stateName": "Mississippi", "topic": "step_therapy", "title": "Step therapy or fail-first protocol: prescriber override (reenacted by H.B. 856, 2026)", "cite": "Miss. Code Ann. § 83-9-36(1)", "quote": "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.", "url": "https://billstatus.ls.state.ms.us/documents/2026/pdf/HB/0800-0899/HB0856SG.pdf", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:23:39.887Z" }, { "id": "mt-external_review", "state": "MT", "stateName": "Montana", "topic": "external_review", "title": "Standard external review: request", "cite": "Mont. Code Ann. § 33-32-410(1)", "quote": "Within 120 days after the date of receipt of a notice of an adverse determination or a final adverse determination pursuant to 33-32-403, a covered person or, if applicable, the covered person's authorized representative may file a request for an external review with the health insurance issuer.", "url": "https://mca.legmt.gov/bills/mca/title_0330/chapter_0320/part_0040/section_0100/0330-0320-0040-0100.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "mt-step_therapy", "state": "MT", "stateName": "Montana", "topic": "step_therapy", "title": "Coverage of oral therapy -- opioid use disorder", "cite": "Mont. Code Ann. § 33-22-127", "quote": "A health insurance issuer may not impose prior authorization or step therapy requirements for an oral therapy prescription used to treat opioid use disorder.", "url": "https://mca.legmt.gov/bills/mca/title_0330/chapter_0220/part_0010/section_0270/0330-0220-0010-0270.html", "appliesTo": [ "individual", "employer_private" ], "condition": "if the prescription is an oral therapy used to treat opioid use disorder", "letterUse": "letter_when_denial_matches", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "nc-external_review", "state": "NC", "stateName": "North Carolina", "topic": "external_review", "title": "Notice of right to external review", "cite": "N.C. Gen. Stat. § 58-50-77(a)", "quote": "An insurer shall notify the covered person in writing of the covered person's right to request an external review", "url": "https://www.ncleg.gov/EnactedLegislation/Statutes/HTML/BySection/Chapter_58/GS_58-50-77.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:21:21.015Z" }, { "id": "nc-step_therapy", "state": "NC", "stateName": "North Carolina", "topic": "step_therapy", "title": "Access to nonformulary and restricted access prescription drugs", "cite": "N.C. Gen. Stat. § 58-3-221(b1)(1)", "quote": "An insurer shall grant an exception request if the prescribing provider's submitted justification and supporting clinical documentation are sufficient to demonstrate any of the following:", "url": "https://www.ncleg.gov/EnactedLegislation/Statutes/HTML/BySection/Chapter_58/GS_58-3-221.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:21:21.015Z" }, { "id": "nd-external_review", "state": "ND", "stateName": "North Dakota", "topic": "external_review", "title": "External review procedures", "cite": "N.D. Cent. Code § 26.1-36-46(3)(f)", "quote": "A claimant must have up to four months after receipt of notice of an adverse benefit determination to request external review.", "url": "https://ndlegis.gov/cencode/t26-1c36.pdf", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "ne-external_review", "state": "NE", "stateName": "Nebraska", "topic": "external_review", "title": "Request for external review", "cite": "Neb. Rev. Stat. § 44-1306(2)", "quote": "A covered person or the covered person's authorized representative may make a request for an external review of an adverse determination or final adverse determination.", "url": "https://nebraskalegislature.gov/laws/statutes.php?statute=44-1306", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:18:37.666Z" }, { "id": "ne-step_therapy", "state": "NE", "stateName": "Nebraska", "topic": "step_therapy", "title": "Step-therapy override exception", "cite": "Neb. Rev. Stat. § 44-7,115(1)", "quote": "A step-therapy override exception shall be approved by a health carrier or utilization review organization if any of the following circumstances apply:", "url": "https://nebraskalegislature.gov/laws/statutes.php?statute=44-7,115", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:18:37.666Z" }, { "id": "nh-external_review", "state": "NH", "stateName": "New Hampshire", "topic": "external_review", "title": "Right to external review", "cite": "N.H. Rev. Stat. Ann. § 420-J:5-a, I", "quote": "A covered person shall have the right to independent external review of a determination by a health carrier or its designee utilization review entity when all of the following conditions apply:", "url": "https://gc.nh.gov/rsa/html/XXXVII/420-J/420-J-5-a.htm", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:23:39.887Z" }, { "id": "nh-step_therapy", "state": "NH", "stateName": "New Hampshire", "topic": "step_therapy", "title": "Prescription Drugs", "cite": "N.H. Rev. Stat. Ann. § 420-J:7-b, II-a", "quote": "No health benefit plan that provides prescription drug benefits and establishes the specific sequence in which prescription drugs for a medical condition are to be prescribed shall require failure on the same medication on more than one occasion for patients continuously enrolled in the plan.", "url": "https://gc.nh.gov/rsa/html/XXXVII/420-J/420-J-7-b.htm", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:23:39.887Z" }, { "id": "nj-external_review", "state": "NJ", "stateName": "New Jersey", "topic": "external_review", "title": "Independent Health Care Appeals Program (as amended by P.L.2025, c.75)", "cite": "N.J. Stat. Ann. § 26:2S-11(a)", "quote": "A covered person or health care provider may apply to the Independent Health Care Appeals Program for a review of a decision to deny, reduce, or terminate a benefit if the person or health care provider has already completed the carrier's appeals process, if any, and the person or health care provider contests the final decision by the carrier.", "url": "https://pub.njleg.state.nj.us/Bills/2024/PL25/75_.HTM", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "nj-step_therapy", "state": "NJ", "stateName": "New Jersey", "topic": "step_therapy", "title": "Prescription drug benefits (Department of Banking and Insurance regulation, minimum standards for health benefits plans)", "cite": "N.J. Admin. Code § 11:22-5.9(b)(6)", "quote": "The carrier shall establish an approval process to enable health care providers and covered persons to obtain coverage of nonformulary drugs at the same level as formulary drugs where the prescribing health care provider certifies the medical necessity of the drug.", "url": "https://nj.gov/dobi/proposed/re260316njac11_22.pdf", "appliesTo": [ "individual", "employer_private" ], "condition": "if your plan is a fully insured New Jersey health benefits plan that provides prescription drug benefits through a formulary", "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "nm-external_review", "state": "NM", "stateName": "New Mexico", "topic": "external_review", "title": "IRO review of an adverse determination (Grievance Procedures rule)", "cite": "13.10.17.19(A) NMAC", "quote": "Every grievant who is dissatisfied with an adverse determination following internal review of a grievance that involves medical judgment, including a determination based on medical necessity, appropriateness, health care setting, level of care, effectiveness or that the requested health care service is experimental, investigational or unproven for a particular medical condition may request an external review by an impartial IRO appointed by the superintendent at no cost to the grievant.", "url": "https://www.srca.nm.gov/parts/title13/13.010.0017.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T13:33:22.628Z" }, { "id": "nm-step_therapy", "state": "NM", "stateName": "New Mexico", "topic": "step_therapy", "title": "Prescription drug coverage - step therapy protocols - clinical review criteria - exceptions (Laws 2024, SB 135)", "cite": "N.M. Stat. Ann. § 59A-22-53.1(C)", "quote": "When a health insurance policy, health care plan or certificate of insurance restricts coverage of a prescription drug for the treatment of any medical condition through the use of a step therapy protocol, an insured and the practitioner prescribing the prescription drug shall have access to a clear, readily accessible and convenient process to request a step therapy exception determination.", "url": "https://www.nmlegis.gov/Sessions/24%20Regular/final/SB0135.pdf", "appliesTo": [ "individual" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T13:33:22.628Z" }, { "id": "nv-external_review", "state": "NV", "stateName": "Nevada", "topic": "external_review", "title": "Written notice of right to request external review", "cite": "Nev. Rev. Stat. § 695G.245(1)", "quote": "A health carrier shall notify the covered person in writing of the covered person’s right to request an external review to be conducted pursuant to NRS 695G.241 to 695G.310, inclusive,", "url": "https://www.leg.state.nv.us/nrs/nrs-695G.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:14:16.299Z" }, { "id": "nv-step_therapy", "state": "NV", "stateName": "Nevada", "topic": "step_therapy", "title": "Step therapy protocol: exemption process", "cite": "Nev. Rev. Stat. § 695G.1639(3)", "quote": "A managed care organization shall grant a request to exempt an insured from a step therapy protocol made in accordance with the process established pursuant to subsection 2 if the attending practitioner for the insured submits to the managed care organization a statement which provides an adequate justification for the exemption and any documentation necessary to support the statement.", "url": "https://www.leg.state.nv.us/nrs/nrs-695G.html", "appliesTo": [ "individual", "employer_private" ], "condition": "if your plan is issued by a managed care organization such as an HMO", "letterUse": "next_steps_only", "retrievedAt": "2026-10-14T18:14:16.299Z" }, { "id": "ny-external_review", "state": "NY", "stateName": "New York", "topic": "external_review", "title": "Right to external appeal established", "cite": "N.Y. Ins. Law § 4910(a)", "quote": "There is hereby established an insured's right to an external appeal of a final adverse determination by a health plan.", "url": "https://www.nysenate.gov/legislation/laws/ISC/4910", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T17:34:33.869Z" }, { "id": "ny-step_therapy", "state": "NY", "stateName": "New York", "topic": "step_therapy", "title": "Utilization review determinations; step therapy override", "cite": "N.Y. Ins. Law § 4903(c-1)", "quote": "A utilization review agent shall grant a step therapy protocol override determination within seventy-two hours of the receipt of information that includes supporting rationale and documentation from a health care professional which demonstrates that:", "url": "https://www.nysenate.gov/legislation/laws/ISC/4903", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:46:52.822Z" }, { "id": "oh-external_review", "state": "OH", "stateName": "Ohio", "topic": "external_review", "title": "Internal appeal process; external review", "cite": "Ohio Rev. Code § 3922.03(B)", "quote": "Review of a final adverse benefit determination shall be through an external review under section 3922.08, 3922.09, or 3922.10 of the Revised Code.", "url": "https://codes.ohio.gov/ohio-revised-code/section-3922.03", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:18:37.666Z" }, { "id": "oh-step_therapy", "state": "OH", "stateName": "Ohio", "topic": "step_therapy", "title": "Step therapy exemption", "cite": "Ohio Rev. Code § 3901.832(B)", "quote": "Pursuant to a step therapy exemption request initiated under division (A)(1) of this section or an appeal made under division (A)(5) of this section, a health plan issuer or utilization review organization shall grant a step therapy exemption if any of the following are met:", "url": "https://codes.ohio.gov/ohio-revised-code/section-3901.832", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:18:37.666Z" }, { "id": "ok-external_review", "state": "OK", "stateName": "Oklahoma", "topic": "external_review", "title": "Requests for External Review (Uniform Health Carrier External Review Act)", "cite": "Okla. Stat. tit. 36, § 6475.6(B)", "quote": "A covered person or the covered person's authorized representative may make a request for an external review of an adverse determination or final adverse determination.", "url": "https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os36.rtf", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:26:10.448Z" }, { "id": "ok-step_therapy", "state": "OK", "stateName": "Oklahoma", "topic": "step_therapy", "title": "Definitions - practice guidelines for step therapy protocol", "cite": "Okla. Stat. tit. 63, § 7310(C)(2)", "quote": "A health insurance plan shall grant a requested step therapy exception if the submitted justification of the prescribing provider and supporting clinical documentation, if needed, is completed and supports the statement of the provider that:", "url": "https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os63.rtf", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:26:10.448Z" }, { "id": "or-external_review", "state": "OR", "stateName": "Oregon", "topic": "external_review", "title": "External review", "cite": "Or. Rev. Stat. § 743B.252(1)", "quote": "An insurer offering health benefit plans in this state shall have an external review program that meets the requirements of this section and ORS 743B.255", "url": "https://www.oregonlegislature.gov/bills_laws/ors/ors743B.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:14:16.299Z" }, { "id": "or-step_therapy", "state": "OR", "stateName": "Oregon", "topic": "step_therapy", "title": "Step therapy", "cite": "Or. Rev. Stat. § 743B.602(2)(c)", "quote": "Approve a request for an exception to step therapy if the entity determines that the evidence submitted by the prescribing practitioner is sufficient to establish that:", "url": "https://www.oregonlegislature.gov/bills_laws/ors/ors743B.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:14:16.299Z" }, { "id": "pa-external_review", "state": "PA", "stateName": "Pennsylvania", "topic": "external_review", "title": "Standard external review (Insurance Company Law of 1921, Art. XXI, added by Act 146 of 2022)", "cite": "40 P.S. § 991.2164.5(a)(1)", "quote": "A covered person, or the covered person's authorized representative, may file a request for external review with the department within four months after the date of receipt of a notice of an adverse benefit determination or final adverse benefit determination under section 2164.2.", "url": "https://www.palegis.us/statutes/unconsolidated/law-information/view-statute?79&iFrame=true&txtType=HTM&SessYr=1921&ActNum=0284.&SessInd=0", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:21:36.838Z" }, { "id": "pa-step_therapy", "state": "PA", "stateName": "Pennsylvania", "topic": "step_therapy", "title": "Step therapy considerations (Insurance Company Law of 1921, Art. XXI, added by Act 146 of 2022)", "cite": "40 P.S. § 991.2156(a)(1)", "quote": "An insurer or MA or CHIP managed care plan shall consider as part of the insurer's or MA or CHIP managed care plan's prior authorization process a request for an exception to the insurer's or MA or CHIP managed care plan's step therapy criteria.", "url": "https://www.palegis.us/statutes/unconsolidated/law-information/view-statute?79&iFrame=true&txtType=HTM&SessYr=1921&ActNum=0284.&SessInd=0", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:21:36.838Z" }, { "id": "ri-external_review", "state": "RI", "stateName": "Rhode Island", "topic": "external_review", "title": "External appeal procedural requirements", "cite": "R.I. Gen. Laws § 27-18.9-8(a)(1)", "quote": "In cases where the non-administrative adverse benefit determination or the final internal level of appeal to reverse a non-administrative adverse benefit determination is unsuccessful, the healthcare entity or review agent shall provide for an external appeal by an independent review organization (IRO) approved by the commissioner and ensure that the external appeal complies with all applicable laws and regulations.", "url": "https://webserver.rilegislature.gov/Statutes/TITLE27/27-18.9/27-18.9-8.htm", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "sc-external_review", "state": "SC", "stateName": "South Carolina", "topic": "external_review", "title": "Notice of right to request a review", "cite": "S.C. Code Ann. § 38-71-1940(A)", "quote": "A health carrier shall notify the covered person in writing of the right to request an external review and include the appropriate statements and information set forth in subsection (B) at the time the health carrier sends written notice of either an adverse determination or a final adverse determination.", "url": "https://www.scstatehouse.gov/code/t38c071.php", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:23:39.887Z" }, { "id": "sc-step_therapy", "state": "SC", "stateName": "South Carolina", "topic": "step_therapy", "title": "Utilization review programs: minimum standards", "cite": "S.C. Code Ann. § 38-70-20(C)(2)", "quote": "all utilization review agents shall maintain a procedure by which insured or providers may seek reconsideration of appeal of determinations of the utilization review agent", "url": "https://www.scstatehouse.gov/code/t38c070.php", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:23:39.887Z" }, { "id": "sd-external_review", "state": "SD", "stateName": "South Dakota", "topic": "external_review", "title": "Standard external review", "cite": "S.D. Admin. R. 20:06:53:12", "quote": "At any time during the four months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to §§ 20:06:53:03 to 20:06:53:05, inclusive, a covered person or the covered person's authorized representative may file a request for an external review with the director.", "url": "https://sdlegislature.gov/api/Rules/31363.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:29:13.924Z" }, { "id": "sd-step_therapy", "state": "SD", "stateName": "South Dakota", "topic": "step_therapy", "title": "Step therapy override exceptions", "cite": "S.D. Codified Laws § 58-17H-55", "quote": "A step therapy override exception shall be approved by a health carrier, health benefit plan, or utilization review organization if any of the following circumstances apply:", "url": "https://sdlegislature.gov/Statutes/58-17H-55", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:29:13.924Z" }, { "id": "tn-external_review", "state": "TN", "stateName": "Tennessee", "topic": "external_review", "title": "Tennessee Health Carrier Grievance and External Review Procedure Act (Pub. Ch. 980 (2010), § 17)", "cite": "Tenn. Code Ann. § 56-61-116(a)", "quote": "Within six (6) months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to Section 14, an aggrieved person may file a request for an external review with the health carrier.", "url": "https://publications.tnsosfiles.com/acts/106/pub/pc0980.pdf", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "tn-step_therapy", "state": "TN", "stateName": "Tennessee", "topic": "step_therapy", "title": "Step therapy exception process (Pub. Ch. 1020 (2022))", "cite": "Tenn. Code Ann. § 56-7-3502(b)", "quote": "A health carrier, health benefit plan, or utilization review organization shall grant a step therapy exception if one (1) of the following applies:", "url": "https://publications.tnsosfiles.com/acts/112/pub/pc1020.pdf", "appliesTo": [ "employer_private" ], "condition": "if your plan is a group health plan or group health insurance (the part does not reach individual policies, TennCare, CoverKids or Access Tennessee)", "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "tx-external_review", "state": "TX", "stateName": "Texas", "topic": "external_review", "title": "Review by independent review organization", "cite": "Tex. Ins. Code § 4201.401(a)", "quote": "A utilization review agent shall allow any party whose appeal of an adverse determination is denied by the agent to seek review of that determination by an independent review organization assigned to the appeal in accordance with Chapter 4202.", "url": "https://statutes.capitol.texas.gov/Docs/IN/htm/IN.4201.htm", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:06:23.793Z" }, { "id": "tx-step_therapy", "state": "TX", "stateName": "Texas", "topic": "step_therapy", "title": "Step therapy protocol exception requests", "cite": "Tex. Ins. Code § 1369.0546(b)", "quote": "A prescribing provider on behalf of a patient may submit to the patient's health benefit plan issuer a written request for an exception to a step therapy protocol required by the patient's health benefit plan.", "url": "https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1369.htm", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:06:23.793Z" }, { "id": "ut-external_review", "state": "UT", "stateName": "Utah", "topic": "external_review", "title": "Independent review of adverse benefit determinations", "cite": "Utah Code Ann. § 31A-22-629(3)(c)", "quote": "An insured who disagrees with the results of an internal review may submit the adverse benefit determination for an independent review if the adverse benefit determination involves:", "url": "https://le.utah.gov/xcode/Title31A/Chapter22/31A-22-S629.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:23:39.887Z" }, { "id": "ut-step_therapy", "state": "UT", "stateName": "Utah", "topic": "step_therapy", "title": "Health benefit plan procedures related to prescription drugs", "cite": "Utah Code Ann. § 31A-22-661(3)", "quote": "A health benefit plan shall provide an enrollee a justification as to why an enrollee must try a certain drug before a health benefit plan will cover a different prescribed drug.", "url": "https://le.utah.gov/xcode/Title31A/Chapter22/31A-22-S661.html", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:23:39.887Z" }, { "id": "va-external_review", "state": "VA", "stateName": "Virginia", "topic": "external_review", "title": "Standard external review", "cite": "Va. Code Ann. § 38.2-3561(A)", "quote": "Within 120 days after the date of receipt of a notice of the right to an external review of a final adverse determination or an adverse determination if the internal appeal process has been deemed to be exhausted or waived, a covered person or his authorized representative may file a request for an external review", "url": "https://law.lis.virginia.gov/vacode/title38.2/chapter35.1/section38.2-3561/", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:18:37.666Z" }, { "id": "va-step_therapy", "state": "VA", "stateName": "Virginia", "topic": "step_therapy", "title": "Step therapy protocols", "cite": "Va. Code Ann. § 38.2-3407.9:05(F)", "quote": "A step therapy exception request shall be granted if the prescribing provider's submitted justification and supporting clinical documentation, if needed, are determined to support the prescribing provider's statement that:", "url": "https://law.lis.virginia.gov/vacode/title38.2/chapter34/section38.2-3407.9:05/", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:18:37.666Z" }, { "id": "vt-external_review", "state": "VT", "stateName": "Vermont", "topic": "external_review", "title": "Independent external review of health care service decisions", "cite": "8 V.S.A. § 4063(b)", "quote": "A covered individual who has exhausted all applicable internal review procedures provided by the health insurance plan shall have the right to an independent external review of a decision under a health insurance plan to deny, reduce, or terminate health care coverage or to deny payment for a health care service.", "url": "https://legislature.vermont.gov/statutes/fullchapter/08/107", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:29:13.924Z" }, { "id": "vt-step_therapy", "state": "VT", "stateName": "Vermont", "topic": "step_therapy", "title": "Prescription drug coverage", "cite": "8 V.S.A. § 4092(d)(1)(B)", "quote": "grant an exception to its step-therapy protocols upon request of a covered individual or the covered individual’s treating health care professional under the same time parameters as set forth for prior authorization requests in 18 V.S.A. § 9418b(g)(4) if any one or more of the following conditions apply:", "url": "https://legislature.vermont.gov/statutes/fullchapter/08/107", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T19:29:13.924Z" }, { "id": "wa-external_review", "state": "WA", "stateName": "Washington", "topic": "external_review", "title": "Independent review of health care disputes", "cite": "Wash. Rev. Code § 48.43.535(2)", "quote": "An enrollee may seek review by a certified independent review organization of a carrier's decision to deny, modify, reduce, or terminate coverage of or payment for a health care service", "url": "https://app.leg.wa.gov/rcw/default.aspx?cite=48.43.535", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:26:50.747Z" }, { "id": "wa-step_therapy", "state": "WA", "stateName": "Washington", "topic": "step_therapy", "title": "Prescription drug utilization management: exception request process", "cite": "Wash. Rev. Code § 48.43.420(3)", "quote": "An exception request must be granted if the health carrier or prescription drug utilization management entity determines that the evidence submitted by the provider or patient is sufficient to establish that:", "url": "https://app.leg.wa.gov/rcw/default.aspx?cite=48.43.420", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:26:50.747Z" }, { "id": "wi-external_review", "state": "WI", "stateName": "Wisconsin", "topic": "external_review", "title": "Independent review of coverage denial determinations", "cite": "Wis. Stat. § 632.835(2)(a)", "quote": "Every insurer that issues a health benefit plan shall establish an independent review procedure whereby an insured under the health benefit plan, or his or her authorized representative, may request and obtain an independent review of a coverage denial determination made with respect to the insured.", "url": "https://docs.legis.wisconsin.gov/statutes/statutes/632/vi/835", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:18:37.666Z" }, { "id": "wi-step_therapy", "state": "WI", "stateName": "Wisconsin", "topic": "step_therapy", "title": "Step therapy protocols", "cite": "Wis. Stat. § 632.866", "quote": "An insurer, pharmacy benefit manager, or utilization review organization shall grant an exception to the step therapy protocol if the prescribing provider submits complete, clinically relevant written documentation supporting a step therapy protocol exception request and any of the following are satisfied:", "url": "https://docs.legis.wisconsin.gov/statutes/statutes/632/vi/866", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-14T18:18:37.666Z" }, { "id": "wv-external_review", "state": "WV", "stateName": "West Virginia", "topic": "external_review", "title": "Issuer requirements", "cite": "W. Va. Code § 33-16H-2", "quote": "An issuer shall, in accordance with rules promulgated pursuant to section four of this article, develop processes for utilization review and internal grievance procedures and shall make external review available with respect to all adverse determinations.", "url": "https://code.wvlegislature.gov/33-16H-2/", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "wv-step_therapy", "state": "WV", "stateName": "West Virginia", "topic": "step_therapy", "title": "Step therapy", "cite": "W. Va. Code § 33-16-3aa(c)(2)", "quote": "A step therapy override determination request shall be expeditiously granted if:", "url": "https://code.wvlegislature.gov/33-16-3AA/", "appliesTo": [ "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "wv-step_therapy-individual", "state": "WV", "stateName": "West Virginia", "topic": "step_therapy", "title": "Step therapy", "cite": "W. Va. Code § 33-15-4o(c)(2)", "quote": "A step therapy override determination request shall be expeditiously granted if:", "url": "https://code.wvlegislature.gov/33-15-4O/", "appliesTo": [ "individual" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T13:31:22.337Z" }, { "id": "wy-external_review", "state": "WY", "stateName": "Wyoming", "topic": "external_review", "title": "Payment of claims under medical necessity standard; review", "cite": "Wyo. Stat. Ann. § 26-40-201(f)", "quote": "Within one hundred twenty (120) days of receiving the written explanation required by subsection (e) of this section, a claimant may request an external review of the decision which is the subject of the explanation by filing a written request for such review.", "url": "https://wyoleg.gov/statutes/compress/title26.pdf", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:23:39.887Z" }, { "id": "wy-step_therapy", "state": "WY", "stateName": "Wyoming", "topic": "step_therapy", "title": "Continuity of care for enrollees: step therapy", "cite": "Wyo. Stat. Ann. § 26-55-111(d)", "quote": "No enrollee shall be required to repeat a step therapy protocol if that enrollee, while under their current or a previous health benefit plan, used the prescription drug required by the step therapy protocol, or another prescription drug in the same pharmacologic class with a similar efficacy and side effect profile or with the same mechanism of action, and discontinued use due to lack of efficacy, effectiveness, an adverse event or contraindication.", "url": "https://wyoleg.gov/statutes/compress/title26.pdf", "appliesTo": [ "individual", "employer_private" ], "condition": null, "letterUse": "letter", "retrievedAt": "2026-10-15T11:23:39.887Z" } ] }