Through COCCI, you have heard about the insurance practice called step therapy or fail first and the movement to put patient protections on its use. A step therapy protocol requires a patient to try and fail an insurer’s preferred drug therapy before they can receive coverage for the medication recommended by their physician.1 Furthermore, patients may have to repeat this process if they switch insurance plans.1
Because of concerns many patient groups have about step therapy requirements being applied inappropriately and harming patients, debate has been underway in many state capitols and on Capitol Hill. Proposals vary on how best to address the concerns, but they often include time limits for insurers to respond to requests for exceptions, a list of specific scenarios that must be exempted, and a clear and transparent process for requesting an exception.1,2
These debates have resulted in significant progress. To date, 35 states have passed laws placing reasonable guardrails around the use of step therapy by state-regulated insurers, which include individual and small-group plans, as well as fully insured employer plans, but not self-insured employer plans.3,4 But in 2010, there were no such state laws. What happened between then and now? Patients happened! With a persistent drumbeat of advocacy including contacting elected officials, providing testimony at hearings, and collaborating with medical societies and other stakeholders, patients are winning the day.
While changing policy usually is not easy, it’s possible, and of course it’s part of a healthy democracy. Whether it’s step therapy or something else you care about, consider the influence of your patient voice to drive policy change. When you combine your power with that of others, a tidal wave can result.
- SAIM Coalition. What is step therapy? Accessed January 9, 2023. https://saimcoalition.org/state-access-to-innovative-medicines/step-therapy/
- National Psoriasis Foundation. Step therapy news. Accessed January 9, 2023. https://www.steptherapy.com/step-therapy-news/
- Aimed Alliance. Step therapy–enacted laws. Accessed January 9, 2023. https://aimedalliance.org/step-therapy-enacted-laws/
- National Psoriasis Foundation. Step therapy legislation by state. Updated January 2023. Accessed January 9, 2023. https://www.steptherapy.com/step-therapy-legislation-by-state/