January 3, 2017 - New York Governor Andrew Cuomo kicked off 2017 by signing the Step Therapy Reform bill (S.3419C/A.2834D) this weekend, joining seven other states who have passed similar legislation in recent years. The bill was a top priority for MS activist in New York who made hundreds of calls, held in-person meetings, and posted to elected officials social media pages in a grassroots effort to drum up support for the bill.
Known as "fail first," step therapy policy are a form of utilization management that health plans may use as a mechanism to control the order in which patients take certain therapies. Step therapy protocols require that patients must try at least one medication selected by their insurer before the plan will grant coverage for the drug originally prescribed by the healthcare provider. Through this method, insurers often require a patient to try a lower-cost drug or service, before they will cover a more expensive option.
S.3419C/A.2834D, which took effect January 1st, will regulate insurance companies, health maintenance organizations (HMOs), and utilization review agents who impose step therapy protocols on patients, and will provide an expedited appeals process for patients and their health care professionals to override such protocols.
The law will expedite the process of step therapy and specifically:
- Require health insurance companies to provide patients and health care professionals with specific written information on their clinical review criteria relating to a decision made to utilize a step therapy protocol.
- Define key terms such as "step therapy protocol override determination" and "Step therapy protocol."
- Requires a utilization review agent to utilize evidenced-based and peer reviewed clinical review criteria that is appropriate for a patient's medical condition when establishing a step therapy protocol.
- Provide an expedited process for patients and health care providers to override a step therapy protocol. A determination must be made within 24 hours of the receipt of all information from the patient and/or health care provider in emergency cases.
- Establishes standards for an override determination. Upon a determination that the step therapy protocol should be overridden, the health plan must authorize immediate coverage for the prescription drug prescribed by the patient's treating health care provider.
- Provides that if an insurance company or utilization review agent fails to respond within the required timeframes, the appeal shall be deemed granted in favor of the patient.
MS activist Karen Waldron and Advocacy Director Jennifer Muthig
held an interview on Capital Tonight, as did Dr. Nilay Shah
, to highlight to bills impact on people living with MS. Letters to the editor from MS activists were also placed in the Times Herald-Record
, the Utica Observer Dispatch
, and the Journal News (lohud)