The Massachusetts Medical Society wishes to be recorded in support of H.1853 and S.1235, essentially identical bills that would implement new protections for patients when they are required to use “Step Therapy” or “Fail First” protocols and would create a process for a patient to appeal a required step therapy protocol.
Step Therapy necessitates the "fail first" drug therapy requirements, in which patients are forced by insurers to try, and fail, with one or more medications before the cost of the medication originally prescribed will be covered. This process ultimately wastes critical time in treatment, which some patients simply cannot afford to lose.
H.1853 and S.1235 would implement the following patient protection provisions to remove unnecessary barriers and allow patients to gain access to the medication they need at a faster pace:
- Requires health insurers to use evidence-based and peer reviewed clinical review criteria that also considers the needs of the patients.
- Provides a standardized appeals process that can be used by a patient’s physician to request a step therapy override if he/she believes the drug(s) being requested by the health insurer is not in the best interest of the patient.
- Requires health insurers, when conducting the review of a request for a step therapy override, to use recognized, evidence-based, and peer reviewed clinical review criteria appropriate for the patient and his/her medical condition.
- Requires health insurers to disclose to health care providers and patients, upon written request, their clinical review criteria relating to a step therapy override determination.
These important provisions would expedite the treatment process for patients who cannot afford to lose valuable time to adhere to insurance policies’ procedures and would allow physicians, who are most in-tune with the patients’ specific needs, to make the ultimate and best decision on the best possible course of medical treatment.
Similar legislation was signed into law in New York in 2016 (Chapter 512 of the Laws of 2016). That law took effect on January 1, 2017; however, it applied to health insurance plans delivered, issued for delivery, or renewed after that date. Also, like Massachusetts, that law enjoyed strong support from a broad range of health care providers and associations.
The MMS urges the Health Care Financing Committee to act favorably on H.1853 and S.1235.
