Quiet But Significant Victories Against Step Therapy Abuse

While public attention was focused on hard-fought midterm elections, patient care advocates in Pennsylvania and Massachusetts quietly won major victories. 

Early this month, the Governors of both states signed into law restrictions on insurers’ ability to use step therapy to delay or deny patients the drugs prescribed by their physicians. Now, over 30 states have similar patient protections in place. 

High Risks for Patients 

Also called “fail first,” step therapy occurs when patients are forced to try one or more health plan preferred drug before gaining access to the one their doctor prescribed.  

The process of delaying access to physician prescribed medications is both frustrating and risky. Forcing patients with rheumatoid arthritis, asthma or heart disease, for example, to try a less desirable – and possibly off label – medication first can lead to uncontrolled symptoms, unchecked disease progression, even emergency care. 

And it’s not only an issue for commercially insured patients. Some state Medicaid programs, like West Virginia’s, require mental health patients to step through two different atypical antipsychotics before accessing the provider preferred treatment. Considering the side effects often associated with antipsychotic medications, this puts patients at risk of unintended consequences that could be avoided if given direct access to the medication their health care provider prescribed.  

Creating Guardrails 

Most of the state laws, including those in Pennsylvania and Massachusetts, don’t prohibit step therapy entirely. Rather, they create guardrails limiting how it can be applied. Most also simplify and create more transparency around what can be a complex appeals process.  

Additional states are expected to take up the issue in the new year, meanwhile Congress continues consideration of the Safe Step Act. The federal legislation is a significant advocacy priority for the advocacy community. It would add federal protections for people who have ERISA plans, a contrast to current rules that permit step therapy for some Medicare plans. In 2019, the Centers for Medicare and Medicaid Services authorized Medicare Advantage Plans to use step therapy for Part B drugs, which are those administered in a doctor’s office or outpatient center. Despite protests, CMS is, so far, sticking to its policy. 

Despite recent patient protection victories, the step therapy reform movement has serious work ahead. That effort will continue to be broadly supported by those who believe in the provision of patient-centered care.