Prohibition on the use of step therapy and prior authorization for qualifying non-opioid pain management drugs under medicare part D

Section 1860D–4(c) of the Social Security Act (42 U.S.C. 1395w–104) is amended— (1) by redesignating paragraph (6), as added by section 50354 of division E of the Bipartisan Budget Act of 2018 (Public Law 115–123), as paragraph (7); and (2) by adding at the end the following paragraph: (8) Prohibition on use of step therapy and prior authorization for qualifying non-opioid pain management drugs (A) In general For plan years beginning on or after January 1, 2026, a prescription drug plan or an MA–PD plan may not, with respect to a qualifying non-opioid pain management drug (as defined in section 1860D–2(b)(10)(B)) for which coverage is provided under such plan, impose any— (i) step therapy requirement under which an individual enrolled under such plan is required to use an opioid prior to receiving such drug; or (ii) prior authorization requirement. (B) Step therapy In this paragraph, the term step therapy means a drug therapy utilization management protocol or program that requires use of an alternative, preferred prescription drug or drugs before the plan approves coverage for the non-preferred drug therapy prescribed. (C) Prior authorization In this paragraph, the term prior authorization means any requirement to obtain approval from a plan prior to the furnishing of a drug..