Step Therapy Appeal and Override Process Improvement
The Richmond Academy of Medicine
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 insurers 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. Delays in appropriate treatment can result in significant and potentially permanent complications for patients. 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 throughout the Commonwealth of Virginia (ideally in concert with local, state and national patient organizations), work to improve the step therapy appeal and override processes in Virginia using legislation similar to that passed in 18 other states as a model.
Background information can be found on pages 61-62 of appendix