Imagine a patient with Type 2 diabetes goes to her local pharmacy to pick up her prescription for medication to manage her blood sugar levels.
When she goes to the prescription counter, her pharmacist explains that her insurance company will not cover the medication without her first “failing” on other medications — in some cases medications she’s already tried.
This process is what’s known as step therapy. It’s a scenario I hear all too often from patients in my role as a diabetes educator — and it affects far more than just Georgians living with diabetes.
Step therapy is utilized by health insurance plans in an attempt to contain costs. It requires patients to “try and fail” medications the insurer dictates before receiving the treatment determined by their physician to be the most appropriate and effective.
Unfortunately, very little oversight of step therapy exists. There is also a lack of evidence showing these “fail first” policies are effective or take into consideration adverse effects of insurance company’s preferred medications.
Some of the common chronic disease states that are targeted for step therapy are diabetes, cancer, hypertension, HIV/AIDs, rheumatoid arthritis and hepatitis C.
Patients put through step therapy commonly face lengthy appeal processes, which lack appropriate health care professional oversight, as well as inconsistent and outdated guidelines for medication recommendations.
Already, 18 states have passed legislation that is designed to reign in step therapy. I hope Georgia will soon become one as well.
During the 2018 legislative session earlier this year, Rep. Sharon Cooper, long-term serving chairwoman of the Health and Human Services Committee, and Sen. Kay Kirkpatrick introduced bills to reform step therapy in Georgia.
These bills would have limited step therapy and fail first protocols and were championed by patient groups from across the state, many of whom had personal stories of how step therapy had affected their members.
The diligent work of Chairwoman Cooper paid off when her bill passed the House unanimously. Unfortunately, despite support from a number of lawmakers in the Senate, the bill ultimately did not advance.
Regardless, the work done by Chairwoman Cooper and Sen. Kirkpatrick deserves applause, and it is my hope that during the upcoming session, both the Georgia House and Senate will take action to cut through the red tape of step therapy on behalf of Georgia patients.
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