In 2019, Georgia lawmakers passed House Bill 63, legislation which:
Ensures that step therapy protocols are based on clinical guidelines developed by independent experts.
Establishes a basic framework for when it is medically appropriate to exempt patients from step therapy, as well as an exceptions process that is transparent and accessible to patients and health care providers.
States That Have Enacted Step Therapy Legislation
More than 20 states, including Virginia, Louisiana, West Virginia & Kentucky, have taken similar actions.
Georgia law improves the step therapy process in the following ways:
Requires step therapy exceptions to 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 step therapy with an exception when:
1. The 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 treatment deemed by their health care provider to meet their medical needs.
Requires health insurance plans to incorporate step therapy exception processes in their pre-authorization applications.
Prohibits insurers from requiring insured patients from having to fail on 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.