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Bill introduced to put protections in place for step therapy

Senators Peggy Lehner (R-Kettering) and Charleta Tavares (D-Columbus) introduced Senate Bill 56 which would put into place protocols for insurance companies that utilize step therapy (also known as fail first).

Step therapy is a cost savings tool used by health insurers to limit how much they spend covering patient's medications. Under step therapy, a patient must try one or more medications chosen by their insurer - usually based on financial, not clinical, considerations - before coverage is granted for the medication prescribed by the patient's physician.

Step therapy protocols can be harmful to patients both financially and physically, causing an undue wait for the proper treatment and in some cases a worsening of a person’s medical condition.  Step therapy does not take into account an individual’s medical history or other factors, but instead relies upon a pre-determined prescription drug formulary or protocol.

Step therapy undermines what physicians believe is the best treatment for patients based on their knowledge of the patient's overall health and ability to tolerate certain medications.

While S.B. 56 does not do away with step therapy all together, it puts into place patient protections, including:

  1. Requiring that an insurer's process for requesting a step therapy override is transparent and available to the patient and the provider.
  2. Allowing automatic exceptions to step therapy requirements when:
    • the required prescription drug is contraindicated or will likely cause an adverse reaction
    • the required prescription drug is expected to be ineffective
    • the patient has previously tried the required drug or a drug in the same pharmacologic class and the drug was ineffective or caused an adverse event
    • the required prescription drug is not in the best interests of the patient based on medical appropriateness
    • the patient is stable on a prescription drug for the medical condition under consideration
  3. Ensuring that step therapy programs are based on clinical guidelines developed by independent experts.

S.B. 56 is scheduled for sponsor testimony in the Senate Health, Human Services and Medicaid committee on Tues., Feb. 21.

The OPPA has taken a position of Active Support with Technical Assistance.

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