In June, state lawmakers in New York passed legislation on step therapy designed to help ensure patient access to the best and most appropriate care.
Step therapy mandates that a patient with a specific condition receive prescribed drugs approved for that condition in the order that an insurance company determines it will cover as the first, second, third, etc., line of treatment. Sometimes the order of prescribed drugs is different than the order preferred by the physician, but the patient must comply with the step therapy protocol or the insurer likely won’t pay for treatment.
[Editor’s note: Check out one patient’s story in Massachusetts, where legislation on step therapy is pending.]
Legislative Requirements
The bill (A2834D, 2016) specifically requires health insurance companies to:
- Base step therapy on appropriate clinical practice guidelines or published peer review data;
- Exempt patients from step therapy when it is inappropriate or not in the best interest of the patient, and
- Allow patients access to a “fair, transparent, and independent process for requesting an exception to a step therapy protocol when the patients’ physician deems appropriate.” (See A2834D. Assemb. Reg. Less. 2015-2016. NY 2016.)
“The legislation will provide accelerated pathways to override step therapy when medically appropriate,” says Howard Blumstein, MD, a member of the New York State Rheumatology Society and chair of the American College of Rheumatology (ACR) Affiliate Societies Council.
Where the ACR Stands
Saying that the ACR is not inherently opposed to the concept of step therapy and recognizes its use by insurance companies to control cost, Dr. Blumstein emphasized, however, that step therapy can impede patients from accessing needed medications.
“Many patients are faced with changing insurance plans, and often, each insurer will have its own set of step therapy protocols,” he says. “If a patient is stable on a medication and they switch plans, they should not have to fail a medication that they [have] tried previously to satisfy insurance requirements.”
In recognition of the many rheumatology patients for whom stable and consistent treatment is necessary, the ACR Affiliate Society Council collaborated with the New York State Rheumatology Society, the Arthritis Foundation, the Lupus and Allied Diseases Association, and the Lupus Agencies of New York State to lobby for the legislation. One of the primary missions of the ACR Affiliate Society Council is to help state rheumatology societies develop and flourish, and assist in promoting best practices for advocacy at the state level.
