About Rx in Reach
Rx in Reach – a project of Advocates for Responsible Care, in partnership with the Rx in Reach GA Coalition – is dedicated to helping insured Georgians access the treatments they need. We support legislation to limit step therapy, as well as policies to keep out-of-pocket costs affordable for insured families in our state.
About Advocates for Responsible Care (ARxC)
Advocates for Responsible Care is a a 501(c)3 advocacy organization that focuses on informing the public, especially the patients, about all health care advocacy issues. It advocates on behalf of ensuring full access to medical care for all Georgians.
About the Rx in Reach GA Coalition
Rx in Reach GA Coalition is a 24-member health-centered organizations advocating for legislation that ends the financial and discriminatory barriers to securing vital medications. Rx in Reach GA Coalition has helped create and support legislation that provides limitations on step therapy/fail first protocols. Step therapy is a health insurance protocol that requires patients to first try a less expensive drug on a prescription drug list before moving up a "step" to a more expensive drug. This approach is also called "fail first” protocol.
When coverage of a prescription drug is blocked because of step therapy protocols, the patient and prescribing doctor must have access to a clear, convenient and expeditious process to a step therapy exception determination. This exception will allow the doctor to prescribe the best drug for the patient's medical needs.
The Rx in Reach GA Coalition, Medical Association of Georgia (MAG) and its supporters believe the following provisions are essential to protect patients:
·Step Therapy exceptions shall occur within twenty-four (24) hours in an urgent health care situation and seventy-two (72) hours in a non-urgent healthcare situation.
·Permits a prescriber to override the step therapy with an exception when:
1) a required drug is contraindicated
2) the required drug has been tried and failed previously
3) the required drug will not be effective or if the patient is already stable on another drug
4) requiring patients to follow a step therapy protocol may have adverse and even dangerous consequences for the patient
5) using the protocol may cause patients to not receive the best and treatment deemed by their health care provider to meet their medical needs.
·Requires health insurance plans to incorporate step therapy exception processes in their preauthorization applications.
·Prohibits insurers from requiring insured patients from having to fail a prescription medication more than once.
·In circumstances where an insured is changing health insurance plans, the new plan may not require the patient to repeat step therapy when that person is already being treated for a medical condition with a prescription drug provided that is considered safe and effective for the patient’s condition.
·When a health insurance plan changes formulary design, the plan cannot limit or exclude coverage for a drug previously approved for coverage by the plan for a specific medical condition.
·Ensures that health plans step therapy protocols be based on well-developed scientific, practice standards and the physicians’ knowledge of the patient’s condition and drug regime and administered in a flexible manner that takes into account the medical individual needs of patients.