Here is a detailed look at each.
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Addressing Step Therapy
Step therapy or fail first protocols require patients to try and fail one or more formulary-covered drugs before the insurer will cover other agents prescribed by the physician, even when the prescriber is certain the insurer-preferred treatment will be ineffective. The ACR’s new position statement opposes utilization management strategies based solely on cost instead of medical value; supports formulary change transparency and involvement of rheumatologists in pharmacy review committees; and calls non-medical switching, or an insurer requiring a patient to switch therapies for cost-saving purposes only and without the patient’s consent, “inappropriate.”
“This position statement continues to emphasize the ACR’s belief that utilization management strategies based solely on cost—including step therapy, fail first policies and tiering of medications—are not appropriate, and often compromise safety and quality of care,” says Colin Edgerton, MD, chair, Committee on Rheumatologic Care. “The ACR remains active with legislators and policymakers addressing the impact of step therapy on patients and their rheumatologists.”
On April 11, a bipartisan bill to place reasonable limits on step therapy’s use by insurers, the Safe Step Act (H.R. 2279), was introduced in the U.S. House of Representatives by Rep. Raul Ruiz, MD (D-Calif.), and Rep. Brad Wenstrup, MD (R-Ohio), a move applauded by the ACR.
“This bill, if enacted, would allow us to bypass step therapy restrictions when we know a drug or mechanism of action won’t work, or is contraindicated or inaccessible for a specific patient due to their comorbidities or specific disease manifestations,” says Angus Worthing, MD, Government Affairs Committee chair. “It’s a critical time to speak up about this bill, because we anticipate it will have broad bipartisan appeal. But House leadership needs to [hear] from our members of Congress [about the significance of this bill], and the Senate needs to introduce and, ultimately pass, the bill as well, in order for it to become law.”
What can you do to support the ACR’s position? Email your representatives through the ACR’s Legislative Action Center form, and encourage your patients to email their representatives through the ACR’s Simple Tasks website.
The ACR’s new position statement on drug pricing supports “safe, convenient and affordable access” to rheumatology treatments, says Dr. Edgerton.