Too many Georgians face barriers that keep them from affordable access to medications and treatments. One of these problems is step therapy, which was fixed with the passing of Georgia House Bill 63 (Step Therapy Reform), signed on April 25, 2019 by Gov. Brian Kemp.
Read on to learn more about step therapy and your rights under the Step Therapy Reform law.
What is Step Therapy?
Step therapy is health insurance protocol (also known as "fail first") requiring Georgians to try and fail on one or more medications before getting coverage for the medication that was originally prescribed.
Who is Affected?
Step therapy often applies to Georgians living with a wide range of diseases and chronic conditions including cancer, autoimmune diseases, epilepsy, HIV/AIDS, diabetes and more.
Why is Step Therapy a Problem?
Step therapy second-guesses providers, and often causes patients' health to deteriorate as they try – and fail on – medications which aren’t right for their condition and can even cause additional health issues. Another problem is that there is currently no clear appeals and exemption process in Georgia so that physicians can override a step therapy protocol if it threatens a patient’s health.
The end result of step therapy often include negative health consequences, increased health care costs and lost productivity for employees. Too many Georgia patients are being kept from the medications they need to live a healthier life.
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.
Kristine was taking an infusion to treat RRMS (Relapsing-Remitting Multiple Sclerosis), only to receive notification that her insurance company found it "not medically necessary," resulting in a $62,000 bill. Her infusion would not be covered until she "tried and failed" on two other MS therapies. The drugs selected by the insurance company could have caused very serious complications.