Advocacy Results from Austin

During the 2017 regular legislative session, the National MS Society and a coalition of over 35 local, state and national organizations successfully passed significant step therapy reform. SB 680 by Senator Kelly Hancock and Representative Greg Bonnen will impact health plans in January and is one of the strongest bills of its kind passed nationwide to date.

Step therapy protocols, also known as “fail first” requirements, are used by insurance companies to review the use of prescription drugs and control costs. A patient may be required to try, then fail on lower-cost or older drugs selected by their insurance company before coverage is granted for the drug prescribed by the patient’s health care provider.For patients living with MS, prolonging ineffective treatment (and delaying access to the right treatment) may result in increased disease activity, loss of function and possible irreversible progression of disability.

What does this legislation do?

• Ensures step therapy protocols are based on widely-accepted clinical guidelines so that medicine – not cost – dictate requirements. 
• Create a clear and expeditious process to protect patients from being required to try or stay on a step therapy medication if it would:
  • create a significant barrier to compliance; 
  • worsen a comorbid condition; 
  • is contraindicated; or 
  • decrease the patient's ability to achieve or maintain reasonable function.
• Protect patients whose conditions are well-controlled on a prescription from being required to try a new medication if step therapy protocols are added at contract renewal
• Prohibit insurers from requiring patients to fail on a prescribed medication more than once, even if the patient switches to a different health insurance company.
• Creates an expedited exceptions request that requires insurers to respond to a written request from a healthcare provider within 72 hours and 24 hours in the case of an emergency.
• If the step therapy bypass request is denied, allows patients to access an expedited appeals process and receive a determination from an independent review organization within 72 hours and within 24 hours in the case of an emergency. 

Who is impacted by Texas Step Therapy Reform?
Individuals with state-regulated plans will benefit from step therapy reform. An easy way to tell if this applies to you? Look at your insurance card: if you see DOI or TDI in the bottom left corner of the front of your card, you have a state-regulated insurance plan.