Limiting Step Therapy Policies to Protect Patients

An increasing number of health plans are utilizing step therapy/fail first policies requiring patients to try and fail on less expensive medications before providing coverage for the originally prescribed medication.

This practice negatively impacts patient outcomes through improper treatment and failures to account for medically necessary indications. In some cases, patients may be required to fail on more than five different medications for nearly two years before being allowed to use their preferred drug.

Moreover, step therapy/fail first policies increase physicians’ administrative burden. Research has shown that for a medical practice to administer insurance each year, the average physician spends a total of almost three weeks a year interacting with health plans, while 23 weeks of nursing staff time and 44 weeks of clerical staff time are required.

This year, the California Rheumatology Alliance is a proud co-sponsor of Assembly Bill 374 which was introduced by Assembly member Adrin Nazarian.  AB 374 would require health care plans to have clinically accepted guidelines for step therapy, create an easy exception process for medical necessity, and prevent step therapy / fail first requirements for a patient if a physician determines that it would be medically inappropriate.

UPDATE: On June 2, the bill passed the Assembly and now moves to the Senate for consideration.

Our Position

CRA supports legislation limiting fail first and step therapy policies, ensuring that patients have access to their livesaving medications and streamlining administrative simplification for the physician’s office.

CRA supports physicians being notified if any fail first or step therapy policy is being implemented.

CRA does not support placing patients in a medically compromised position to fail on a medication.

Quote

“A physician’s medical decision making expertise in consultation with his patients should drive treatment decisions” – Gary Feldman, MD, CRA President