Health advocates from across Ohio visited the Ohio Statehouse on February 10 to lobby for Senate Bill 243 (SB 243), and the newly introduced companion bill, House Bill 443 (HB 443), both of which address step therapy, or “fail first” requirements imposed by health plans. The Ohio Academy of Family Physicians is a member of the Ohio Step Therapy Coalition and strongly supports both bills—proposals that will help patients get the medicines their physicians prescribe for them.
Under step therapy, an insurer denies coverage of a prescribed medication, requiring that the patient first try a different medicine, usually at less cost to the health plan. The patient must “fail first” on the drug chosen by the insurer, at which point the health plan may require additional steps – other medications – before approving the original prescription from the prescriber.
Step therapy is increasingly used by insurers. In 2010, nearly 60% of health insurers reported using step therapy, and in 2013, 75% of large employers reported offering plans that utilize step therapy.
Mental Health America of Franklin County was represented among Ohio organizations that attended the advocacy day.
“It’s important to note that this legislation doesn’t eliminate step therapy,” said Kenton Beachy, executive director of Mental Health America of Franklin County. “Controlling costs is important, but too often, it is at the expense of what’s best for the patient. Particularly for Ohioans with mental illnesses, ‘fail first’ policies can mean serious health setbacks. These patients; and others who are battling cancer, Alzheimer’s, diabetes, and other diseases; should not get worse before they can get better. Ohio SB 243 and HB 443 will provide more patient protections when step therapy occurs.”
- Require that step therapy decisions be based on medical guidelines developed by independent experts. This will make step therapy safer for patients.
- Specify conditions under which it is medically appropriate to exempt patients from step therapy. This might include cases in which the patient is already stable on the physician-prescribed medication or cases where the patient has already tried the drug required by the insurer and it didn’t help.
- Require insurers to have a clear, quick process for physicians to request an override to step therapy. Studies show that 20% of patients who are denied the medication they were prescribed end up not taking any prescription medication at all. Their treatment is effectively delayed, with possible consequences for their health.
SB 243 is sponsored by Senators Peggy Lehner (R-Kettering, OH) and Charleta Tavares (D-Columbus, OH). HB 443 is sponsored by Representatives Terry Johnson (R-Portsmouth, OH) and Nickie Antonio (D-Lakewood, OH).
So far six states (Connecticut, Kentucky, Louisiana, Maryland, Mississippi, and Washington) have passed a law requiring more accountability and transparency from insurers when it comes to step therapy. California recently passed legislation that requires insurers to accelerate their response time to exceptions and appeals. Ohio is among 10 states currently considering legislation.
- Academy of Medicine of Cleveland & Northern Ohio
- American Academy of Dermatology
- American Cancer Society, Cancer Action Network
- American Diabetes Association
- American Lung Association, Ohio and Michigan
- Arthritis Foundation, Great Lakes Region
- Cancer Support Community, Cincinnati
- Central Ohio Diabetes Association
- Chi Eta Phi Sorority Inc.
- Cincinnati Area Senior Services Inc.
- Columbus Chapter, Black Nurses Association
- Chrohn’s & Colitis Foundation of America
- Chrohn’s & Colitis Foundation of America, Central Ohio Chapter
- Chrohn’s & Colitis Foundation of America, Northeast Ohio Chapter
- Chrohn’s & Colitis Foundation of America, Southwest Ohio Chapter
- Epilepsy Foundation, Western Ohio
- Health Disparities Collaborative of Ohio Inc.
- Leukemia and Lymphoma Society
- Lupus Foundation of Greater Cleveland
- Mental Health & Addition Advocacy Coalition
- Mental Health America of Franklin County
- National Alliance on Mental Illness, Ohio
- National Liver Foundation, Heartland Division
- National Organization for Rare Disorders
- National Patient Advocate Foundation
- National Psoriasis Foundation
- Ohio Academy of Family Physicians
- Ohio Asian American Health Coalition
- Ohio Association of County Behavioral Health Authorities
- Ohio Association of Rheumatology
- Ohio Bleeding Disorders Council
- Ohio Chapter, American College of Surgeons
- Ohio Dermatological Association
- Ohio Hematology Oncology Society
- Ohio Osteopathic Association
- Ohio Psychiatric Physicians Association
- Ohio Sickle Cell and Health Association
- Ohio State Medical Association
- Prescription Assistance Network of Stark County Inc.
- Prevent Blindness Ohio
- The Epilepsy Association (Serving Northeast Ohio)
- The Ohio Council of Behavioral Health and Family Service Providers
- U.S. Pain Foundation.