House panel backs curbs on ‘step therapy’ rules
When Brannen Whirledge was diagnosed with ulcerative colitis at age 4, he was put on medications that failed to help him. He suffered continual vomiting and severe stomach cramps.
Then they found a medication that worked. Brannen’s symptoms went away.
But after six months, says his mother, Melissa Whirledge, the family’s insurer told them that it would no longer cover the effective medication until “he failed on other drugs that he had already failed on.”
The family appealed that ruling, and Brannen, now 7, has received exceptions to the drug restrictions. He is doing well, his mother says.
The insurer drug protocols that the Atlanta family faced are known as “step therapy.” They require that a patient “try and fail” on one or more meds before insurers provide coverage for a drug that was originally prescribed.
The House Insurance Committee on Wednesday passed legislation that would help patients obtain exceptions to these drug requirements.
“We are very supportive of the legislation, not only for our son, whose future depends on it, but for all other patients,” Whirledge says.
An identical bill passed in the Georgia House last year, but went no further. Rep. Richard Smith (R-Columbus), chairman of the House Insurance Committee, said the 2018 step therapy legislation “got tied up in some personality problems and politics in the Senate.”
Rep. Sharon Cooper (R-Marietta), lead sponsor of House Bill 63, told the committee that under the legislation, “if a physician documents information, the patient will get the medication they need. This is a bill that helps patients.”
Advocates for patients say insurers often require step therapy for people with serious conditions, such as cancer, multiple sclerosis, diabetes and arthritis.
House Bill 63 would establish a process for health care providers to request exceptions. These exemptions would include:
The required drug is expected to cause an adverse reaction or physical or mental harm to the patient.
The required medication is expected to be ineffective based on the clinical condition of the patient and the characteristics of the drug.
The patient has tried the required drug under current or previous health insurance and it was discontinued due to lack of efficacy, diminished effect, or an adverse event.
The patient’s condition is stable on a prescription drug previously selected by a medical provider for the condition targeted.
The bill would require a health plan to grant or deny an exception to its drug protocols within 24 hours in an urgent health care situation, and in two business days for a non-urgent case. Georgia Health News, a nonprofit 501(c)3 organization, tracks state medical issues on its website georgiahealthnews.com.