State Step Therapy Laws: Not All Are Created Equal

Step therapy reform has been a hot topic and major focus of the ACR’s advocacy activity in states this legislative session. Washington, Oregon, Wisconsin and Florida are all considering step therapy bills that stand good chance of passing this legislative year. Virginia and Georgia have already passed step therapy laws. When these two new laws take effect, 19 states will have step therapy laws on the books. However, not all step therapy laws are created equally.

What We Need
Although any progress on step therapy reform is typically better than the status quo, the ad hoc approach some states take creates barriers to additional reforms. Chief among these barriers is the fact that legislators are often reluctant to revisit matters they thought were fully resolved. For this reason, the ACR supports step therapy reform that includes the following:

• Clear step therapy protocol guidelines that allow for overrides when:
  • A medication is contraindicated;
  • A patient has already failed the medication;
  • A patient is stable on their current medication;
• A 24-hour decision window for emergency override requests;
• A 72-hour decision window for non-emergency override requests; and
• A clear and expedient appeals process.

What We Have
Many states enact laws that include only some of these provisions. Practitioners in states that do not have a comprehensive step therapy law often report that there has been no improvement in step therapy override processes or the paperwork associated with getting an override approved. California is perhaps the best example of this phenomenon.

The ACR has had substantial feedback from California physicians indicating the paperwork required for step therapy override requests has not been reduced. The enforcement mechanism to punish violators of the statute is also inadequate. California is not alone in problematic approaches to step therapy.

Ohio passed step therapy reform late last year. This bill was widely championed as a substantial late session win. Although the bill contains much to praise, one section of problematic language in the step therapy override exceptions has started to show up in step therapy bills in other states: Patients who are stable on their current medications can remain on them, but this exception allows insurers to require patients try a pharmaceutical alternative from the FDA’s orange or purple book before the insurer is required to cover the patient’s medication. This bill will not go into effect until January 2020, so the jury is still out on how this loophole will affect patients, but the impacts could be significant and disruptive.