Infuse Your Policy Strategy – July Updates

Step Therapy is a strategy that insurance companies use to make patients try and “fail” a cheaper medication before the health plan will cover the medicine their doctor prescribed. This insurance tactic, also known as “Fail First,” is harmful to patient health and safety. Imagine you are a vegetarian and order a delicious cheese and mushroom pizza at a restaurant. But when the waiter comes to set the hot pie on the table, you see that there are pepperonis all over it. Not what you ordered. The server explains that, at this restaurant, diners are required to try the pepperoni pizza first. Patrons must prove their disgust before they can eat what they ordered. We wouldn’t allow this behavior at our local restaurants, so why would we allow it in our healthcare system, when it comes to our health?  Luckily, some states are considering or have already passed bills that limit step therapy. For instance, some of these bills require insurance companies to respond to exception requests or appeals from your doctor within a strict time period so that you aren’t left in the dark, waiting to hear if the right medicine for you will be covered.

In Massachusetts, the House of Representatives passed a step therapy bill on June 29, 2022. H 4929 will guarantee a transparent appeals process for all step therapy situations. The bill is not yet a law, but is on its way. The next step is for the state Senate’s Ways and Means Committee to consider and approve the bill. Once the bill is approved by the committee, the full Senate will vote on whether or not to pass the bill. Should the bill pass the full Senate, it will go to the governor’s desk where Governor Charlie Baker will decide to sign the bill into law or veto. If the bill does become law, it would define when a step therapy exception is granted. In other words, there would be a law keeping insurance companies in check when it comes to their use of step therapy. In order to pass the House, state lawmakers had to make some compromises. While this redrafting process weakened the bill to a degree, other proposed changes were left out of this draft thanks to the Patients for Prescription Access (PFPA), a healthcare advocacy coalition of which IAF is a member. IAF signed a letter with our PFPA peers asking the Senate to support and strengthen this bill.

If you live in Massachusetts and want to help, send a note to your representatives here asking them to support step therapy reform! We have written the main points for you, but feel free to customize the letter with your own thoughts. Additionally, if you live in Massachusetts and would like to share your step therapy story with us, please email kindyl.boyer@patientaccess.org.

It is important to note that state bills will only protect patients with state-regulated plans. Therefore, if you receive health insurance through your employer, you are not protected by state step therapy legislation. Thankfully, there are other forces at work with a bipartisan bill called the Safe Step Act (S. 464/H.R. 2163). This is a federal bill, meaning that if it were passed into law, it would apply to the whole country. The Safe Step Act would offer critical patient protections by establishing five basic situations where exceptions to step therapy must be granted. This progress would block the most harmful cases of step therapy, including switching a patient who is already stable on a medication to another medication. This legislation requires employer-sponsored plans to establish a clear, convenient, and readily available exceptions process and establish a timeline for appeals. Let your U.S. Congress representatives know that you support the Safe Step Act by sending a note through IAF’s advocacy campaign. Customize your letter and tell your story. Your voice matters.