Legislation has been introduced in (State) to address this serious and widespread issue. The bill (name of bill) is sponsored by Senator (Name) and Assemblyman (Name) and would establish two simple patient protections: • A clear and abbreviated process that prescribers may use to override a step therapy protocol in cases where evidence demonstrates that it is medically necessary • A limit on the amount of time a patient can be required to try different medications This legislation applies to commercial plans regulated by the State and is supported by (Organization) and a coalition of patient advocacy organizations, other health providers including (Organization) and others. It is currently under review in the Insurance Committee in each house. Key Findings of the Surveys: • Over 64% of physicians said only some health insurers permit them to attempt to override a step therapy protocol and 30% said none of the insurers they work with allow them to do so • Over 93% of physicians said it was “challenging” or “extremely difficult” to override health insurers’ step therapy protocols to assure their patients get the medications they need • Over 98% of physicians said the process to exempt patients from step therapy requirements was “challenging” or “extremely challenging” • Over 50% of physicians said it can take a minimum of 2 days to more than one week to override an insurers’ step therapy protocol • Over 56% of physicians said the process to exempt patients from step therapy protocols can take a minimum of 1–2 weeks or longer • 65.5% of physicians said that they had to repeat a step therapy protocol for the same patient • When asked how step therapy policies affect patients, more than 95% of physicians said they delay access to appropriate therapies, 64% said they decrease medication adherence, and nearly 61% said they increase non-medication costs Comments Provided in Surveys: • Drugs that insurers require patients to fail first on were often not in the same class as the drug initially prescribed and there are potentially adverse drug to drug interactions • Step therapy restrictions are now the most time consuming issue in his/ her practice • A recent example was provided of a patient who ended up in the emergency department with a seizure after the insurer did not approve (Product Name) • Step therapy requirements cause physical and emotional harm to patients forced to trial cheap, ineffective drugs • One insurer requires patients to try four atypical antipsychotics for three months before the newer brand name drug will be covered • Patients often have to wait several weeks to receive anti-cancer drugs, during which the cancer progresses and they deteriorate • A physician noted that he/she has been forced to use a medication that he/she knew would be harmful in order to get the one he/she wished to prescribed for children • A physician said that every year the insurer’s step therapy policy starts over so he/she has had to take patients off medications they have been stable on, calling this a dangerous policy
Examples have been provided by advocacy and professional societies and have been de-identified. For illustrative purposes only.
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