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Safe Step Act

Health plans employ various cost containment protocols known as “Utilization Management (UM).” The result of UM is that your insurance plan has the final word on what treatment you will get even though you and your doctor have already made that decision. Step Therapy is a UM protocol that often results in delayed access to needed care.

Here is an example of Step Therapy: A medical provider prescribes a specific medication for a patient’s chronic condition. But, often not until the patient is at the pharmacy counter, do they find out they must go through step therapy first and try another, insurer-preferred medication before it will authorize payment for the prescribed treatment.  Such “fail first” procedures can take weeks and even months to prove failure before being allowed access to the medication the doctor first prescribed.  Trying Step 1 medication could lead to Step 2 medication and up the step “ladder.” The potential for devastating patient outcomes while going through the step exercise is real.

In response to the immediate denial of access to prescribed treatments and the mandatory step alternatives required by health plans, more than half the states have passed legislation requiring an exception process for mandatory step therapy. The legislation brings clear, time-sensitive procedures and bases for the patient or provider to get an exception and, when necessary, an appeal.

However, there remains a significant insured population in those and all states that remain outside a state’s insurance authority – Employment Retirement Security Act (ERISA) plans. To address those ERISA insureds, federal legislation was needed. HR 2163 and S 464 – Safe Step Act – would amend existing ERISA provisions to offer an exception process to step therapy similar to most state legislation. The legislation is currently working its way through the congressional procedural regimens.  The Chronic Care Policy Alliance with other patient advocacy organization are actively supporting the Safe Step Act.