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Legislation introduced to improve insurers' use of "step therapy" policies


Ohio Health Advocates Applaud Senate Bill 243 to lower step therapy hurdle

Physicians, not health plans, should determine best prescriptions for patients’ health

FOR IMMEDIATE RELEASE: Wednesday, November 18, 2015                                                                       

Contact: Jenny Camper 614-224-0658                                                                                                                    

Columbus, OH – Newly introduced state legislation will help Ohio patients get the first and best medication their doctors say will work for them. State Senators Peggy Lehner (R- Kettering) and Charleta Tavares (D-Columbus) are co-sponsoring Senate Bill 243, which would establish guidelines health insurers must follow when they impose "step therapy" requirements. Health advocates in Ohio are praising the bill’s potential to help patients get the medications they need.

Under step therapy, an insurer denies coverage of a prescribed medication, requiring that the patient first try a different medicine, usually at less cost to the health plan. The patient must "fail first" on the drug chosen by the insurer, at which point the health plan may require additional steps – other medications – before approving the original prescription from the medical professional.

Step therapy is increasingly used by insurers. In 2010, nearly 60 percent of health insurers reported using step therapy, and in 2013, 75 percent of large employers reported offering plans that utilize step therapy.

"We are all interested in controlling healthcare costs," said Shannon Trotter, D.O., president of the Ohio Dermatological Association and with the Division of Dermatology at The Ohio State University and in private practice in Springfield. "But step therapy is being used with patients who have debilitating and sometimes life-threatening illnesses including diseases of the skin such as psoriasis, and cancer. Patients with Alzheimer’s, diabetes and other diseases experience step therapy too. To require these patients to 'fail first' on a cheaper medication often means letting the disease get worse before allowing the patient to have the medication his or her doctor feels is best. We absolutely need some structure around how and when step therapy is practiced."

Senate Bill 243 would not prohibit step therapy, but it would set up conditions for its use. The bill would:

  • Require that step therapy decisions be based on medical guidelines developed by independent experts. This will make step therapy safer for patients.

A recent assessment showed that 18 of the nation's largest insurers who were asked to cover a biologic or immunologic drug (often used to treat autoimmune diseases) instead required patients to try medications carrying "black box warnings" of side effects like serious infections, tuberculosis, and cancer. This happened even when the medication requested by their healthcare provider did not carry any such black box warnings. In other words, patients were prescribed medicine that had less serious side effects, and the insurer replaced it with medicine that had potentially more severe side effects.

  • Specify conditions under which it is medically appropriate to exempt patients from step therapy. This might include cases in which the patient is already stable on the physician-prescribed medication, or cases where the patient has already tried the drug required by the insurer and it didn't help.
  • Require insurers to have a clear, quick process for physicians to request an override to step therapy. Studies show that 20 percent of patients who are denied the medication they were prescribed end up not taking any prescription medication at all. Their treatment is effectively delayed, with possible consequences for their health.

“In the long-term, step therapy can impact many aspects of a patient’s life. Delay in getting to the best health outcome can affect a person’s ability to thrive and work. The stress of waiting and of battling a health plan for the right treatment can be especially hard for seniors, for people with low literacy or English skills, and for people who are profoundly ill,” said Dr. Trotter.  

So far six states (Connecticut, Kentucky, Louisiana, Maryland, Mississippi and Washington) have passed a law requiring more accountability and transparency from insurers when it comes to step therapy. Ohio is among 11 states currently considering legislation.

See related story OPPA Executive Director, Janet Shaw "With mental illness, there's no time for fail first." 



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