Many allergists have contacted us about payer step-therapy requirements and what can be done to ensure patients get the treatments they need. What is step-therapy, exactly? It’s when third-party payers require patients to try less expensive options before “stepping up” to more expensive drugs. Patients are forced to try and fail a medication before the originally prescribed medication can be covered. This can lead to serious negative patient outcomes resulting from delays in effective treatment.
The Advocacy Council has been supporting efforts in several states to pass laws curtailing the ability of payers to impose unreasonable step-therapy requirements. Eighteen states have already passed such laws – Arkansas, California, Colorado, Connecticut, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Mississippi, Missouri, New Mexico, New York, Oregon, Texas, and West Virginia. These laws do not prohibit step-therapy but most impose limits based on clinical criteria and require timely override procedures.
States with pending step-therapy legislation include Florida, Georgia, Maine, Massachusetts, Minnesota, New Jersey, Ohio, Rhode Island, Utah, Virginia, and Washington. If you are in one of the states with pending legislation and want to get involved, contact the Advocacy Council.
If you are not in a state with existing or pending legislation and are concerned about step-therapy restriction, contact your state medical society to see if they are working on this issue.
If you’re having problems getting medications approved due to prior authorizations, check out the College’s Prior Authorization toolkit. It’s full of tips and tricks from allergy prior authorization experts. It features our ground-breaking prior authorization appeal letter generator tool, which lets you create customized, scientifically-based appeal letters for specific biologics/disease combinations. Members have had great success with this tool, so make it part of your practice’s appeal process.