Bill would ease getting pricier prescribed drug
Physicians and patient advocates are pushing during the final weeks of the legislative session for passage of a bill they say would shorten ailing Ohioans’ wait for their doctor’s first choice of medication.
The bill targets a practice called step therapy, which is used by insurers to control prescription-drug costs by requiring patients to use cheaper drugs first. If those don’t work, the patients can try more-expensive medicine prescribed by their doctor.
Supporters of the bill say the pursuit of lower drug prices is putting patients’ lives at risk by delaying treatment, often causing complications and added costs.
Health insurers and other critics argue that the legislation would increase health care costs for consumers, employers and the state, which operates the taxfunded Medicaid program.
At a Statehouse press conference Tuesday, state Sen. Peggy Lehner, R-Kettering, who is one of the bill’s sponsors, said, “This bill is not about eliminating step therapy. Step therapy is a perfectly valid way to control costs and make sure patients have a drug that works for them.”
“However, there are exceptions to the rules, and this bill is about making sure that some of those exceptions are in the law so that patients not only have the most cost-effective drug, but they also have the most medically effective one.”
State Rep. Scott Lipps, R-Franklin, knows firsthand how someone can see their health deteriorate when forced to try a cheaper medication.
“About a year ago, I grew ill ... and in November received an uncomfortable diagnosis, but I really trusted my specialist. I’d known him my whole life. I went to the pharmacy to pick up my first prescription, and the pharmacist said, ‘You can’t have that, Scott. It was denied by your insurance company,’” Lipps said.
“After 60 days with a horrible side effect and absolutely no impact on my tumor, I raised a lot of hell” and won approval of the doctor’s recommended medication. “Within 14 days, I saw a dramatic reversal of my condition. I’d lost about 50 pounds. I had an immediate stop of the loss of weight and gained a few pounds back. I started feeling better. I started looking better. I started living again. No side effects.”
After discussing his experience, Lipps didn’t disclose his condition but said he’s “successfully battling an illness.”
Senate Bill 56 and the identical House Bill 72 would streamline the process patients must follow to override “fail first” requirements when their doctor says a medicine is needed for their health. Health insurers also would have to respond to requests for step-therapy exemptions within 72 hours, and, under some circumstances, within 24 hours.
The current process can be lengthy. Stephanie McCarroll, a nurse at Cleveland Clinic’s Asthma Center, said she spent “two hours, seven minutes and 58 seconds on the phone” with insurers after switching a patient’s medication from one that wasn’t working to one that did.
Supporters have been pushing for the legislation for four years and are urging legislators to approve the measure before adjourning in December. Eighteen states have enacted similar bills.
Opponents, including the Ohio Association of Health Plans, say the legislation would be an unfunded mandate on health insurers and drive up prescription costs.
“We oppose legislative mandates that hinder pharmacy benefit managers’ ability to reduce costs and improve the quality of pharmacy benefits,” said Greg Lopes, spokesman for the Pharmaceutical Care Management Association. “Step therapy is a valuable tool to ensure patients get the most clinically appropriate and affordable treatment possible. Employers, unions, and public programs use tools like step therapy and prior authorization in their pharmacy benefits in order to reduce inappropriate drug use, lower costs and improve quality.”