BOSTON – Tuesday, June 29, State Rep. Kathy LaNatra joined her colleagues in the Massachusetts House of Representatives to pass legislation limiting the use of step therapy protocols, in which insurance companies refuse to pay for the prescription drugs prescribed by a patient’s health care provider until the patient first tries cheaper, and oftentimes ineffective, alternatives. The legislation establishes exceptions a patient can use to avoid their insurer’s step therapy protocol and requires both MassHealth and commercial insurers to provide a clear and transparent process for patients and their care team to request an exception.
“Health care decisions and decisions regarding which medications to take should be made between a patient and their doctor, not insurance companies looking for a healthier bottom line,” said State Rep. Kathy LaNatra (D – Kingston). “I was proud to support this crucial piece of legislation to ensure that people with a myriad of diseases and conditions don’t have to delay care with ineffective treatments that worsen their condition, simply to cut costs for insurance companies. That is not the way to cut health care costs in the Commonwealth. Thank you to Speaker Mariano and Chairman Lawn for their leadership on this bill.”
The legislation outlines four different circumstances that trigger the patient exception process, including:
The required treatment will harm the patient,
The required treatment is expected to be ineffective,
The patient previously tried the required treatment, or similar treatment, and it was ineffective or harmed the patient,
The patient is stable on a current treatment, and switching treatments will harm the patient.
Additional highlights of the legislation include:
• A requirement that MassHealth and commercial insurers adopt a “continuity of coverage” policy to ensure patients do not experience any delay in accessing a treatment when requesting a step therapy exemption.
• A requirement that MassHealth and commercial insurers approve or deny a step therapy exemption request within three business days, or within one business day if a delay would cause harm to the patient.
• A requirement that commercial carriers annually report data related to step therapy exemption requests and related coverage determinations to the Division of Insurance.
• The creation of a commission on step therapy protocols tasked with studying, assessing, and bi-annually reporting on the implementation of step therapy process reforms made in this legislation.
“An Act Relative to Step Therapy and Patient Safety” (H.4929)passed the House of Representatives 153-0. The legislation now heads to the Senate for their consideration.