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States regulating insurers’ use of ‘step therapy’ to ensure patients get access to the drugs they need

by Jon Davis ~ March 2019 ~ Stateline Midwest »
Can health insurance companies dictate what medications you use? Yes, if they use a “step therapy” protocol.
Step therapy (also known as “fail first”) requires a patient to begin treatment with the most cost-effective drug therapy, progressing to more expensive or risky treatments only if necessary. The idea, as with other kinds of prior authorizations — pre-approval to prescribe a specific drug or treatment — is cost control.
“Requiring prior authorization in a drug benefit can effectively help avoid inappropriate drug use and promote the use of evidence-based drug therapy,” the American Academy of Managed Care Pharmacy said in a 2012 paper, adding it “can minimize overall medical costs.”
Five Midwestern states — Illinois, Indiana, Iowa, Minnesota and Ohio — have laws regulating insurers’ use of step therapy, spelling out when patients are exempt and providing a window (usually 72 hours) for companies to grant or deny exemption requests (if no reply is given, the exception is then granted).
Similar legislation has been introduced this year in Kansas (HB 2120 and SB 93), North Dakota (HB 1469 and SB 2290) and Wisconsin (AB 24 and SB 26). These laws and bills typically allow for exemptions if:
• the required step-therapy drug is deemed to be medically inappropriate or inadvisable;
• the patient has tried the required prescription drug, and the doctor submits evidence of failure or intolerance; or
• the patient’s medical condition is already stable on the prescription drug that he or she is taking.
Angie Thies, the National Psoriasis Foundation’s state government relations manager for the central region, recommends exemptions for two other types of circumstances: 1) when a prescription drug under step therapy is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug regimen; or 2) if the required drug is not in the best interest of the patient, based on medical necessity.
Wisconsin’s AB 24 has all five of these exemptions.
Rep. John Nygren says enshrining these exemptions in state law “provides transparency to a confusing process for patients and doctors” and enhances the doctor-patient relationship. He became aware of step therapy, and the need to occasionally override it, via his work with Wisconsin’s opioid task force. But he doesn’t oppose step therapy overall.
“I do think there’s a value; it can be a cost control measure, and cost control has to be a part of the health care conversation,” he says.


Article written by Jon Davis, CSG Midwest staff liaison for the Midwestern Legislative Conference Health & Human Services Committee.