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July 16, 2019

6/22/2019 7:30:00 AM
Step therapy reform legislation heads to governor
Bill updates insurer policy that delays access to prescribed medications

Richard Moore
Investigative Reporter

The state Assembly this week unanimously passed legislation which supporters say will improve the insurer process known as step therapy and allow greater access to needed medications for patients with chronic conditions.

The bill now heads to the governor for his signature.

Step therapy is a protocol insurers commonly use to govern the order in which patients utilize certain therapies approved for a diagnosed condition. Under step therapy, patients are sometimes required to try alternative prescription drugs chosen by their health plan before coverage is granted for the drug prescribed by the patient's provider, according to the Wisconsin Academy of Family Physicians.

Step therapy protocols are used in the treatment of such chronic conditions and diseases as Alzheimer's, cancer, diabetes, HIV/AIDS, and mental health. But the WAFP says, in some cases, step therapy protocols can negatively impact patients who need access to the pharmaceuticals their physicians prescribe.

The bill headed to Gov. Tony Evers' desk would maintain an insurer's ability to set step therapy protocols but also give physicians the ability to supersede those protocols when medically necessary and appropriate.

"We'd like to thank Wisconsin Assembly members for hearing their constituents and realizing patients with chronic, progressive, and complex conditions should no longer have to suffer through the step therapy process," said Angie Thies, state government relations manager for the National Psoriasis Foundation and leader of Wisconsin Step Therapy Coalition, a statewide organization representing individuals with chronic disease and health care providers.

"Both sides of the aisle agreed that forcing people to try and fail first on medications other than the ones their doctor prescribed was not only unfair, but in many cases, very harmful to a patient's health," she said.

Now, Thies said, thanks to a bipartisan effort, protections will be put in place that provide better access for patients to get the right medicine at the right time.

"Physicians and patients will once again be given a voice in the process and the result will be better health outcomes for all," she said.

Rep. Mary Felzkowski (R-Irma) also highlighted the bill as a key reform in this legislative session.

"Step therapy is a situation where health insurance plans mandate that patients try less expensive, and possibly less efficient medications, first," Felzkowski said. "Now, we've voted to make the process simpler and fairer for patients in Wisconsin, getting people the treatment they need without red tape in the way."

Rep. John Nygren (R-Marinette), a co-sponsor of the bill, said he and bill author Sen. Alberta Darling (R-River Hills) were amazed at the outpouring of support and personal stories they received after the bill was introduced.

"It reminded us that the work we do here in Madison has a direct impact on the families of Wisconsin, and how important expeditiously moving this legislation is," Nygren said. "At the public hearing, people from all over Wisconsin came to tell us their story, and how this bill will positively impact their lives."

After working with various health insurance groups, patient advocates, and healthcare providers, Nygren said everyone arrived at a bill which keeps patient protections, while still ensuring health plans have the ability to meaningfully utilize step therapy protocols to keep costs down.

Wisconsin Academy of Family Physicians president Dr. Lisa Dodson was equally effusive.

"Senate Bill 26 ensures physicians, rather than insurance companies, have the tools to determine the best course of treatment for a patient," Dodson said. "WAFP is grateful to Sen. Darling and Rep. Nygren for bringing this legislation forward. WAFP actively advocated for this bill throughout the legislative process. We are very pleased to see the Legislature heard our stories and acted to address our patients' needs."

The bill

The bill does not abolish step therapy, but instead provides strict criteria for when a provider can request an override. Supporters say similar step therapy legislation has become law in more than 20 states.

According to an analysis by the Legislative Council, the bill requires an insurer, pharmacy benefit manager, or utilization review organization to grant an exception to a step therapy protocol if the prescribing provider submits complete, clinically relevant written documentation supporting a step therapy exception request and any one of certain conditions are satisfied.

Those conditions include if the prescription drug required under the step therapy protocol is contraindicated or due to a documented adverse event with a previous use or a documented medical condition is likely to cause a serious adverse reaction, decrease the ability to achieve or maintain reasonable functional ability in performing daily activities, or cause physical or psychiatric harm to the patient.

If the prescription drug required under the step therapy protocol is expected to be ineffective based on sound clinical evidence or medical and scientific evidence, an exception can be made, as well as when the patient has tried the prescription drug required under the step therapy protocol, and the patient's use of the prescription drug was discontinued by the patient's provider due to lack of efficacy or effectiveness, diminished effect, or adverse event.

Similarly, if the patient is stable on a prescription drug selected by his or her health care provider for the medical condition under consideration while covered under the policy or plan or a previous policy or plan, an exception will be granted.

The bill also requires a decision within a certain number of business days. Specifically, the legislative council analysis stated, the bill provides that an insurer, pharmacy benefit manager, or utilization review organization must grant or deny a request for any exception to the step therapy protocol within three business days of receipt of the complete, clinically relevant written documentation.

In exigent circumstances, the analysis stated, an insurer, pharmacy benefit manager, or utilization review organization must grant or deny a request for an exception to the step therapy protocol by the end of the next business day after receipt of the complete, clinically relevant written documentation supporting the request.

If the insurer, pharmacy benefit manager, or utilization review organization does not grant or deny a request or an appeal under the time specified, the exception is considered granted.

Richard Moore is the author of the forthcoming "Storyfinding: From the Journey to the Story" and can be reached at

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