Bill allows for exceptions to medication prescription protocols

April 23-- Apr. 23--The Oklahoma legislature recently passed S.B. 509 imposing certain requirements on insurer's use of step therapy protocols. What is a step therapy?

Step therapy is a practice used by insurers that requires people to try lower-cost medications before allowing more expensive treatments, even if a physician has recommended or prescribed another medication. As a result, more expensive drugs can be prescribed only if the cheaper drugs prove ineffective.

Step therapy sounds like a reasonable cost-containment measure for insurers. What's the downside to step therapy?

Problems for patients and their treating providers arise when a patient changes insurance or their current insurer re-classifies a particular drug they are taking causing the patient to have to go through the step protocol again unnecessarily. In essence, it may require the patient to start over with a drug that previously had proven ineffective in treating his/her condition or forgo insurance reimbursement for the drug that the patient needs.

How does S.B. 509 address the problems associated with step therapy protocols?

S.B. 509 requires insurers and utilization review organizations to use recognized, evidence-based and peer-reviewed clinical practice guidelines when establishing any step therapy protocol; and provide to the prescribing provider and patient access to a clear, convenient and readily accessible process to request a step therapy exception.

What are the exceptions to application of a step therapy protocol?

The new statute requires an insurance plan to grant a requested step therapy exception in the following circumstances: the required prescription is contraindicated or will likely cause an adverse reaction; the required prescription is expected to be ineffective based on the known characteristics of the patients and the drug; the patient has tried the required prescription drug and it was discontinued due to lack of efficacy or effectiveness, diminished effect or an adverse event; the required prescription drug is not in the best interest of the patient based on medical necessity; or the patient is stable on a prescription drug selected by the patient's healthcare provider.

Paula Burkes, Business writer

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