As the practice of step therapy grows more pervasive throughout the insurance industry, the protocols become increasingly confusing to navigate. Steps vary from insurer to insurer based on plan type, and formulary differences are too often based on economic incentives rather than outcome-based medicine. Patients are often left hanging in the balance while physicians’ offices help them navigate the step therapy process.
Fortunately, states are now stepping in to help bring some uniformity to the insurance market. Twenty-four states have now passed some variation of step therapy reform. If there’s one word to characterize step therapy practices nationwide, it would be “variable.” Even though states pass reform, physicians may not even notice a difference. Medicare and Employee Retirement Income Security Act (ERISA) based plans are exempt from state reforms because states cannot preempt the federal laws that govern these programs. That is why it is important for you to contact your Congress members and Senators to encourage them to support a federal step therapy bill. You can easily do this through the ACR’s Legislative Action Center.
Only Connecticut, Kansas, Louisiana, New Mexico, New York and Wisconsin have included Medicaid plans in their step therapy reform packages. What about the other components of reform? Here is a brief rundown of where the states stand and how to navigate your state’s step therapy framework.
24-Hour Emergency Response to Override Request
The 24-hour emergency response to an override request is critically important to patients who need rapid treatment. More timely interventions can mean better outcomes for patients, but that requires state policy that recognizes that fact and respects the physician’s right to choose the best drug for the patient.
Nationwide step therapy practices are variable. Only 10 states currently have a 24-hour emergency response to override requirement. Illinois, Indiana, Kansas, New Mexico, New York, Texas and Virginia currently have this provision effective. The Georgia, Oklahoma and Wisconsin provisions will go into effect on Jan. 1, 2020. Washington’s provision will go into effect in January 2021.
Also of note, Ohio has a 48-hour emergency response requirement that will go into effect on Jan. 1, 2020, while Iowa and Minnesota both have a 72-hour emergency response requirement. Although these offer some protections for patients, these are not ideal timelines for emergency cases.
72-Hour or Better Response to General Override Requests
The 72-hour response requirement for general override requests is critical for getting all patients access to the care they deserve. Right now, only 13 states have this requirement. Arkansas, California, Illinois, Indiana, Kansas, New Mexico, New York, Texas and Virginia all have the 72-hour response requirement in effect. Georgia, Oklahoma, and Wisconsin will have this provision effective starting Jan. 1, 2020, while Washington’s will go into effect in January 2021.