Step Therapy Legislation in Georgia
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. Unfortunately, the more expensive drug is often the more appropriate and effective drug prescribed by the patient’s doctor.
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 override or exception determination. This override or exception will allow the doctor to prescribe the best drug for the patient's medical needs.
Rx in Reach GA Coalition supports legislation that provides limitations on step therapy/fail first protocols and believes the following provisions are essential to protect patients:
. Step Therapy override determination or appeal shall occur within twenty-four hours in an urgent health care situation and seventy-two hours in an non-urgent healthcare situation.
· Permit a prescriber to override the step therapy when patients are stable on a prescribed medication.
· Permit a physician to override the step therapy if the physician expects the treatment to be ineffective based on the known relevant physical characteristics of the patient and the known characteristics of the drug regimen; will cause or will likely cause an adverse reaction by or physical harm to the patient; or is not in the best interest of the patient, based on medical necessity.
· Require health insurance plans to incorporate step therapy approval and override processes in their preauthorization applications.*
· Prohibit insurers from requiring insured patients from having to fail a prescription medication more than once.
· Limit any single step therapy protocol to a maximum of 60 days.
· 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 by a prescription drug provided that the drug is appropriately prescribed and 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 if the physician continues to prescribe the drug for that medical condition.
*Rx in Reach Ga Coalition continues to support a single standardize prior authorization form (paper and electronic) on all insurance formulary websites in ‘friendly patient language’ that the patient can complete and bring to the physicians for submission. This would streamline patient access and allow patient/doctor discussion of choices to vital medications and treatments. We support prior authorization requests to be determined within 48 hours of submission or receive automatic approval.
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/