Step Therapy For Georgia - See our Rx in Reach GA Coalition Factsheet (updated October 2017)
Rx in Reach GA Coalition (20 member health centered organizations advocating for legislation that ends the financial and discriminatory barriers to securing vital medications) supports legislation that provides limitations on step therapy/fail first protocols. Step therapy is a health insurance protocol that requires patients to first try a less expensive drug on a Prescription Drug list before moving up a "step" to a more expensive drug. This approach is also called "fail first” protocol.
When coverage of a prescription drug is blocked because of step therapy protocols, the patient and prescribing doctor must have access to a clear, convenient and expeditious process to a step therapy exception determination. This exception will allow the doctor to prescribe the best drug for the patient's medical needs.
The Rx in Reach GA Coalition and its supporters believes the following are a portion of the provisions are essential to protect patients:
. Step Therapy exception shall occur within twenty-four (24) hours in an urgent health care situation and seventy-two (72) hours in a non-urgent healthcare situation.
· Permit a prescriber to override the step therapy with an exception when:
1) when a required drug is contraindicated 2) when the required drug has been tried and failed previously 3) when the required drug will not be effective or 4) if the patient is already stable on another drug 5) requiring patients to follow a step therapy protocol may have adverse and even dangerous consequences for the patient 6) may cause patients to not receive the best and treatment deemed by their health care provider to meet their medical needs.
· Require health insurance plans to incorporate step therapy exception processes in their preauthorization applications.
· Prohibit insurers from requiring insured patients from having to fail a prescription medication more than once.
· In circumstances where an insured is changing health insurance plans, the new plan may not require the patient to repeat step therapy when that person is already being treated for a medical condition with a prescription drug provided that is considered safe and effective for the patient’s condition.
· When a health insurance plan changes formulary design, the plan cannot limit or exclude coverage for a drug previously approved for coverage by the plan for a specific medical condition.
·Ensure that health plans step therapy protocols be based on well-developed scientific, practice standards and the physicians’ knowledge of the patient’s condition and drug regime and administered in a flexible manner that takes into account the medical individual needs of patients.
House Bill 519: http://www.legis.ga.gov/legislation/en-us/display/20172018/hb/519.
Learn more about the dangers of step therapy at Fail First Hurts, an initiative led by the Global Healthy Living Foundation to fight against fail first policies in the United States.
ARxC is a proud member of the 50-State Network, a grassroots advocacy organization comprised of patients and patient advocates that are commtted to sharing the patient perspective with state and federal health policy makers. This community is made up of patients living with diverse chronic illnesss, inlcuding rheumatoid arthritis, lupus, and psoriasis, and the people who care about them.
Join the network at https://www.50statenetwork.org/failfirst-join/