Grassroots Advocacy Tool Kit - Courtesy of BMS


For Immediate Release: (Date) Contact: (Contact Information)

Physician Surveys Find Health Insurer Step Therapy Protocols Harm Patient Care; Organizations Urge Lawmakers to Establish a Fair and Expedited Override Process (City, State) – Today (Organization) and (Organization) announced the findings of recently conducted surveys on health insurer step therapy protocols for prescription medications. Responses were received from over 400 physicians practicing throughout (State) and across many physician specialty areas. Each organization issued its own survey to members yet the physician responses were remarkably consistent. The surveys found that existing insurer step therapy protocols delay and adversely affect patient care, are challenging and time consuming and limit clinical judgment in determining what medication will be most effective for patients. 90% of physicians indicated that step therapy protocols at least “sometimes” adversely affected their patients and 46% indicated that it “frequently” adversely affected patients. The surveys also found that 94% of respondents support the concept of requiring insurers to provide an expedited process to exempt patients from step therapy protocols when the drug they prescribed is medically necessary. “Imposition of step therapy protocols, also known as ‘fail first’, are one way among many that insurance com- panies are limiting needed patient care and treatments to enhance their bottom line” stated (Name, Title) of (Organization). “We have heard from many physicians regarding the difficulties they face from insurers when they and their staff seek to assure their patients have coverage for the prescription medications they need. The surveys further demonstrate the frequency by which insurer rules that require patients to ‘fail first’ on certain medications can have serious consequences for their health. We need legislation or regulatory action to assure our patients can get the medications they need without having to needlessly wait weeks or months to comply with insurance company protocol.” Step therapy is a utilization management tool that health insurers commonly use to control spending on prescription drugs. It functions as a coverage restriction placed on prescription drugs by health plans. These policies require that before the insurer will cover drugs initially prescribed by a physician, the patient must first try other (sometimes multiple), generally less expensive drugs to treat the patient’s condition to see if they will be effective. “The survey findings are very disturbing. Patients are being forced to fail multiple times, some- times for months at a time on ineffective medications before health insurers will cover the right medication to treat conditions,” stated (Organization, Title, Name). “Our members view it as central to our role as family physicians to be advocates for our patients. Time is often of the essence for our patients with serious and debilitating illnesses. We need a clear, fair process that puts medical decision making back in the hands of physicians so patients get the medications that most effectively address their needs.” As supported by the (Organization) and (Organization) surveys, step therapy restrictions are imposed by most health insurers in the State and are applied to prescription drugs treating a wide range of diseases and conditions including autoimmune diseases, cancer, diabetes, HIV/AIDS, mental health, treatment of pain and many others. The list of drugs identified by physicians as being subject to step therapy even included medications such as suboxone which is used to treat opioid addiction-a major focus in (State) this year. Patients need access to these medications without hurdles or delays.

Examples have been provided by advocacy and professional societies and have been de-identified. For illustrative purposes only.


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