Rx in Reach supports legislation that provides limitations on step therapy/fail first protocols and believes the following provisions are essential to protect patients. A dozen states, including Louisiana, West Virginia and Kentucky, have taken similar actions.
Georgia needs legislation which limits step therapy in the following ways:
- Permit a provider to override the step therapy when patients are stable on a prescribed medication.
- Permit a provider n to override the step therapy if that physician expects the treatment to be ineffective based on the known relevant physical characteristics of the patient and the known characteristics of the drug regimen; will cause or will likely cause an adverse reaction by or physical harm to the patient; or is not in the best interest of the patient, based on medical necessity.
Creating a Better Appeals Process
- Require health insurance plans to incorporate step therapy approval and override processes in their preauthorization applications.
- Limit any single step therapy protocol to a maximum of 60 days; adjudicate appeals within 3 days.
Protecting Continuity of Care
- Prohibit insurers from restarting a “step therapy sequence” if patient has already failed on the treatment with current or previous insurer.
- When an enrollee switches health plans, the new plan may not require the patient to repeat step therapy when that person is already being treated for a medical condition by a prescription drug – provided that the drug is appropriately prescribed and 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 patient if the drug has previously been approved for coverage by the plan for a medical condition of the person, and the plan’s prescribing provider continues to prescribe the drug for the medical condition.
How Georgia Can Address High Out-of-Pocket Costs
Rx in Reach supports legislation which would limit the copay or coinsurance for specialty tiers medications to $200 for a 30-day supply.
Who this proposal protects:
- Georgians who need medication to stay healthy and whose medication has been or will be moved from the traditional three-tiered formulary onto a specialty tier.
- Georgians living with chronic or life-threatening diseases such as, but not limited to, epilepsy, cancer, diabetes, hemophilia, multiple sclerosis, HIV/Aids, hepatitis C, and some forms of arthritis and lupus.
- Patients with conditions for which lower cost or generic alternatives often do not exist.
What this proposal WILL do:
- Provides Georgia patients with reasonable access to critical medications.
- Limits what insurers can charge a patient for a 30-day supply of a single prescription drug to $200.
- Preserves the cost-sharing principle upon which insurance is based. Patients who need treatment will not bear an unfair share of the costs.
What this proposal WILL NOT do:
- Prevent insurers from using tiered formularies.
- Force insurers to cover non-formulary drugs.
- Hurt insurer profits. In Louisiana, Maryland and other states that have enacted similar out-of-pocket cost caps, there has been minimal or no financial impact on health insurance plans. Health plans will be free to manage costs in other ways.
- Prevent insurers from using prior authorization, step-therapy, and other utilization management techniques designed to encourage low-cost medications.
- Limit insurers’ flexibility to offer differentiated health plans.
How this proposal will affect Georgia’s finances:
The bill has no financial impact on the state as it does not affect Medicaid. There is no fiscal note attached to the legislation.