GA| Georgia Insurance Commissioner issues Bulletin 25-EX-6, reminding all health benefit plans issued in Georgia—including state employee plans and Medicaid managed care plans—that O.C.G.A. § 33-24-59.20 prohibits the use of step therapy or “fail first” protocols for the treatment of stage four advanced, metastatic cancer. Health plans that directly or indirectly cover treatment for this condition may not limit or exclude coverage for FDA-approved drugs for stage-four metastatic cancer, nor require that a patient first fail on other drugs or prove a history of such failure before authorizing or covering the prescribed drug, so long as its use is consistent with best practices and supported by peer-reviewed medical literature.
The bulletin clarifies that plans cannot impose these requirements either explicitly in coverage criteria or indirectly through prior authorization processes, and it warns that the Department of Insurance will take regulatory action as necessary to enforce compliance.