MS Activists Continue to Advance Step Therapy Reforms
June 5, 2019
To ensure that people with multiple sclerosis are able to access the life-changing medications they need, MS Activists and the National MS Society prioritized reforming step therapy in the states since the publication of the “Make MS Medications Accessible
" recommendations in 2016. Since then, MS activists have been at the forefront of supporting state legislation providing transparent exceptions to insurers’ “fail-first” protocols.
Health insurance plans across the United States often utilize step therapy or “fail first” policies as a cost-management tools, controlling the order in which patients can take certain drug therapies. This approach requires that patients must try one or more medications selected by their insurer before the health plan extends coverage for the drug originally prescribed by the healthcare provider.
As a result, reforming step therapy protocols have become a galvanizing issue for individuals, MS Activists and their coalition partners have seen recent legislative successes in Ohio, Virginia, Georgia, Oklahoma and Washington. With legislation still be being considered in half a dozen states.
The majority of these bills include “override provisions”, outlining circumstances that would overrule the “fail first” protocol, such as evidence of the Step-protocol treatment causing harm or if the patient has previously failed a health plan. Additionally, these legislations often include provisions ensuring that insurers respond to “exception requests” in a timely manner, which patients and their healthcare providers appeal for coverage on the higher-priced drug due to medical necessity.