Senate OKs bill to give patients, doctors, flexibility in insurers’ prescription requirements
STATE HOUSE – The Senate today approved legislation sponsored by Sen. Hanna M. Gallo to give doctors and patients some relief from rigid insurance prescription requirements known as “step therapy.”
Step therapy is a cost-savings tool implemented by the insurance industry that forces patients to try and fail on medications other than what their doctor has prescribed before their insurer will cover the cost of the original medication.
Under step therapy, a patient must try one or more drugs chosen by their insurer — usually based on financial, not medical, considerations — before coverage is granted for the drug prescribed by the patient’s health care provider. Step therapy is applied to drugs treating a wide range of diseases and chronic conditions, including cancer, diabetes, HIV/AIDS, mental health issues and more.
Senator Gallo’s bill (2021-S 0302), which has passed the Senate several times in the past, would give doctors and patients a transparent process to appeal step therapy for patients who need a particular treatment.
“One size does not fit all in health care. Doctors are best able to determine what the best treatment would be for their patients, and requiring patients to fail at other treatments before they can get what their doctor recommends can be very harmful to patients’ health. It is understandable that insurers would prefer that doctors try less-expensive treatments when possible, but there needs to be some flexibility in situations when a doctor has reason to believe a patient shouldn’t do that,” said Senator Gallo (D-Dist. 27, Cranston, West Warwick).
The bill requires that insurers that provide prescription coverage base step therapy protocols on appropriate clinical practice guidelines or published peer review data developed by independent experts with knowledge of the condition or conditions under consideration. It also requires that patients be exempt from step therapy protocols when inappropriate, and that patients have access to a fair, transparent and independent process for requesting an exception to a step therapy protocol when the patient’s physician deems it appropriate.
The act, which would affect insurance policies provided, issued or renewed on or after Jan. 1, 2022, does not ban step therapy or limit the number of steps an insurer can implement.
More than 30 other states have passed similar laws to what is being proposed in Rhode Island.
The bill now goes to the House of Representatives, where Rep. Patricia A. Serpa (D-Dist. 27, West Warwick, Coventry, Warwick) is sponsoring its companion (2021-H 5704).
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