Does your state protect consumers from Step Therapy?

If you have a serious medical condition, it is likely, at some point, that you will be prescribed a brand name medication by your health care team. Your health insurance plan may require you to participate in a process called step therapy before you get access to a brand name medication, even if it prescribed by your doctor.

Step therapy involves a patient trying a generic or lower-cost version of their prescribed drug before “stepping-up” to the brand-name or more expensive drug. If the cheaper drug does not work or the patient has a bad reaction, they may then be allowed to try the more expensive medication.

While generic drugs may work for some patients, this process can hinder other patients’ ability to access the medication they need.

Though there are currently no federal protections in place against the use of step therapy, many states have their own step therapy protections. Currently, states use three kinds of protections against step therapy.

  • Override Processes/Exception Determination Processes: Some states, including Illinois, New Mexico, and Texas, require that insurance companies have override processes (also known as “exception determination processes”) for step therapy. These processes allow patients to request exceptions to step therapy and access the prescribed medication immediately.
  • Prohibiting step therapy: A few states prohibit step therapy entirely, depending on the diagnosis of the patient. Colorado prohibits all insurance companies from using step therapy. North Dakota and Utah prohibit step therapy for patients diagnosed with metastatic cancer.
  • Other Protections: If your state has not mandated override processes or prohibited step therapy, it may have legislation that protects you from step therapy to some degree. In California, legislation requires that health insurers’ step therapy processes be submitted and responded to in the same manner as preauthorization requests. Vermont prohibits insurers from using step therapy processes that require patients to repeatedly try medications. If it did not work the first time, the patient will not have to go through step therapy twice.

For information specific to your state, check out this chart of state laws.

For more information about health insurance coverage:

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Monica Bryant