Re-engaging on Step Therapy in 2016
February 1, 2016 - Last year, CSRO had a number of successes in expanding education for step therapy. In conversations with legislators, the common sense measures of exceptions for step therapy were well received. However, with strong opposition from insurers entrenched in many state legislatures, there was only one legislative success last year, in California.
For 2016, the main coalition on this effort, SAIM (State Access to Innovative Medicines) Coalition, continues to work with model legislation supported by CSRO. This legislation covers five major automatic exceptions to step therapy protocols:
- Previously tried and failed a drug
- The drug is expected to be ineffective based on medical history
- A patient is stable on a current medication
- The drug is contraindicated or would likely cause an adverse reaction
- The treatment is not in the best interest of the patient
In addition, the model legislation also includes provisions that require clinical review criteria for the development of step therapy protocols, and limited time frames for the insurer to respond to step therapy override requests in order to expedite the process of getting a patient their medication.
For 2016, legislation is expected in at least 10 states including Illinois, Indiana, Massachusetts, Missouri, New Jersey, New York, North Carolina, Ohio, Virginia, and West Virginia. In each state, there is still strong opposition from the insurers, but the increased coalition support and momentum from 2015 should give an additional boost to this year’s bills.