TMA Asks Legislators to Make Sure New Step Therapy Law Works

Testimony on Interim Charge No. 6 by Arlo Weltge, MD

Dec. 6, 2017

Thank you, Mr. Chairman and members of the House Insurance Committee for allowing me to testify today. 

My name is Dr. Arlo Weltge. I am an emergency medicine physician from Houston, and I am testifying on behalf of the Texas Medical Association and it’s more than 50,000 members.  

Coverage of necessary and effective prescription drugs is critical for appropriate care of a patient and even more so for those who battle chronic illness. Changes or disruptions in established medication treatment plans that are driven by plan coverage (rather than medical decisionmaking) can be detrimental to a patient’s health and undermine a physician’s clinical decisions.

Furthermore, insurance coverage barriers to patients accessing the medications a physician prescribes have the potential to delay patient receipt of timely care.  

This may occur through the process of “step therapy,” which is the use of a protocol that requires an enrollee to use a prescription drug or sequence of drugs other than the drug the enrollee’s physician recommends before the health benefit plan provides coverage for the recommended drug.

We are appreciative of the passage of Senate Bill 680 by Sen. Kelly Hancock and Rep. Greg Bonnen. This committee and the legislature took a large step in the right direction in helping patients who may be subject to the step therapy process.  

The new step therapy legislation does not contain a prohibition on health plans requiring step therapy protocols. Rather, it provides a more standardized process for physician exception requests to those protocols. It also:

  • Requires a health benefit plan issuer that requires a step therapy protocol before providing coverage for a prescription drug to establish, implement, and administer the step therapy protocol in accordance with clinical review criteria available to the health care industry;
  • Includes uniform exception request criteria;
  • Includes an automatic granting of an exception request unless the request is denied within the required timeframe (72 or 24 hours, depending on the request);
  • Provides that a denial of an exception request constitutes an adverse determination;
  • Provides for expedited review of a step therapy adverse determination; and
  • Provides that a step therapy exception request is subject to the independent review organization (IRO) process and requires a review of a step therapy protocol exception request in generally the same timeframes as for life-threatening conditions and the provision of prescription drugs or IV infusions for which the patient is receiving benefits under the policy.

We had been told that prior to the new legislation, it could take a patient up to 53 calendar days to complete an appeal related to a step therapy protocol.  The new legislation should significantly reduce this timeframe.  

We ask that the legislature monitor the effectiveness of SB 680 to ensure that: (1) it accomplishes its intended impact of removing unnecessary barriers to patient access to medications, and (2) other impediments to patient medication access are not developed or used that may circumvent the important protections implemented in the step therapy legislation. Health plans already use a variety of tactics to limit coverage or utilization of prescription drugs (e.g., imposing dispensing limits, adding prior authorization requirements, changing payment tiers, and removing drugs from formulary lists during plan renewals).

Further study of the drug formularies is warranted to make sure patients and physicians have adequate options when deciding on appropriate pharmaceutical treatment. 

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Last Updated On

May 17, 2018

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