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HB 5988

Insurance: health insurers; coverage for step therapy; modify. Amends sec. 3406t of 1956 PA 218 (MCL 500.3406t).

2025-2026 Regular Session Introduced by Noah Arbit and 18 co-sponsors

HB 5988 requires insurers to offer drug synchronization for maintenance meds, create clear step-therapy criteria, and provide timely, transparent exception decisions.

bill electronically reproduced 05/19/2026
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Bill Summary · HB 5988

Summary of HB 5988 (2025-2026) - Michigan

Purpose and intent

HB 5988 seeks to modify the state’s insurance code as it relates to health insurers’ coverage of step therapy and the synchronization of maintenance prescription drugs. The bill aims to improve patient access to preferred therapies by requiring insurers/HMOs to offer a program to synchronize multiple maintenance drugs for chronic conditions and by establishing a formal, criteria-driven framework for step therapy exceptions.

Key provisions and changes

  • Drug synchronization program (maintenance drugs):
    • Insurers delivering, issuing, renewing health policies or HMOs with prescription drug coverage must provide a program to synchronize multiple maintenance drugs for an individual when:
    • The patient, their physician, and a pharmacist agree synchronization is in the patient’s best interests for a chronic, long-term condition.
    • The drugs meet criteria including eligibility under the policy, use for chronic conditioning treatment with prior authorized refills, non-inclusion of most controlled substances (Schedules 2-5; with an exception for anti-epileptic drugs), adherence to existing prior authorization, formulary compatibility with synchronization, appropriate formulation for short-fill period adjustments, and lack of quantity limits or dose-optimization barriers that would block synchronization.
  • Cost sharing and dispensing fees:
    • When drugs are synchronized, insurers must apply a prorated daily cost-sharing rate for in-network dispenses.
    • However, they may not reimburse prorated dispensing fees; instead, they must pay dispensing fees per each medication dispensed.
  • Step therapy protocol requirements:
    • If a step therapy protocol is used, it must be based on clinical review criteria aligned with practice guidelines and developed by a multidisciplinary, transparent process that manages conflicts of interest, uses a methodologist, and allows public input.
    • Guidelines must be high-quality, continually updated, and capable of subgroup analyses; in the absence of such guidelines, peer-reviewed publications may be substituted.
    • Criteria must account for atypical patient needs.
  • Access to clinical criteria:
    • Insurers/UROs must provide, upon request, all specific clinical review criteria related to a condition and an override determination, and must publish these criteria on their websites.
  • Step therapy exceptions process:
    • An easily accessible process for step therapy exceptions must be available to prescribers, and the insurer must disclose all requirements for submitting complete exception requests.
    • Exceptions must be granted within 72 hours (or 24 hours in exigent circumstances); if additional information is needed, the insurer must specify what is required within 72 hours (24 hours in exigent cases). If information is not provided in time, the exception is deemed granted, with notice of appeal rights if denial occurs.
  • Limitations and flexibility:
    • The bill preserves flexibility for providers to prescribe medically appropriate alternatives and for AB-rated generics or interchangeable biologics under specified conditions.
  • Reporting and accountability:
    • Annually, insurers/UROs must report to the director (in a prescribed format) data on:
    • Number and type of step therapy exception requests and outcomes (approved/denied, initial denials and appeals).
    • Conditions for which exceptions were granted due to potential adverse reactions or lack of response to prior therapies.
  • Definitions:
    • Clarifies terms such as clinical practice guidelines, clinical review criteria, medical necessity, step therapy protocol, step therapy exception, and utilization review organization.

Who is affected

  • Health insurers and health maintenance organizations regulated under Michigan’s Insurance Code (1956 PA 218) that issue or renew plans with prescription drug coverage.
  • Healthcare providers (physicians, pharmacists) who coordinate drug synchronization and file step therapy exception requests.
  • Patients with chronic long-term conditions who rely on maintenance prescription drugs and may benefit from synchronized dosing and clarified exception processes.
  • The Michigan Department of Insurance, which would receive annual reporting from insurers/UROs.

Procedural and timeline aspects

  • Introduced May 14, 2026; referred to the House Committee on Insurance.
  • Requires timely decision timelines for step therapy exceptions: 72 hours normally, 24 hours in exigent circumstances; incomplete information triggers a defined notice to furnish additional details.
  • Annual reporting requirement to the director with specified data elements.

Overall, HB 5988 seeks to reduce barriers to necessary therapies for chronic conditions by formalizing drug synchronization, refining step therapy processes, and enhancing transparency and timeliness in exception handling.

Compiled from official sources — confirm details with the bill’s official record.

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