Commenting for this proposal will be open until the close of business on Monday, June 5.
Title of Proposal:
Resolution to Improve Step Therapy in Virginia
On behalf of:
Richmond Academy of Medicine
Describe the Idea or Issue:
Step therapy or “fail first” protocols are policies, practices and programs established by utilization review agents that establish a specific sequence of interventions for specified medical conditions for enrollees. These protocols appear to be economically based in that they require patients to use a lower cost drug or service before permitting use of more expensive drugs or services. An increasing number of insurers are utilizing step therapy or fail first policies that require patients to try and fail one or more formulary covered medications before providing coverage for the originally prescribed non-preferred or non-formulary medicine, often at the expense of the health of the patient. For example, if a patient changes unsurers or if a drug they are currently taking is moved to a non-preferred or non-formulary status, patients may be put through the step therapy process again even if the patient is stable. This could cause great harm to the patient.
Step therapy is an established benefit management tool used by commercial carriers, self-insured employers, Medicare Advantage/Part D programs, and Medicaid as well as other utilization review agents such as pharmacy, radiology and therapy benefit managers and specialty pharmacies. The decision-making process and/or clinical evidence for the step therapy or fail first protocols and appeal/override decisions are frequently not revealed and often with no transparent, efficient or expedited step therapy or fail first protocol appeal process in exceptional clinical situations.
The act of appealing these protocols creates an undue burden on health care providers, their staff and patients, wasting valuable health care resources and increasing costs.
The Richmond Academy of Medicine would like the Medical Society of Virginia, in collaboration with local and specialty physician organizations across the Commonwealth of Virginia [ideally in concert with local and national patient organizations], to work to reform step therapy in Virginia using legislation similar to that passed in New York and other states as a model.
Please find the following background items in the appendix:
Additional background materials in appendix.