The measure addresses the process known as step therapy, where an insurance company can require a patient to try less expensive treatment options before advancing to more expensive ones originally prescribed by a doctor. Insurance companies argue it’s a reasonable way to keep costs in check before riskier and pricier drugs are prescribed. But opponents say it creates a “fail-first” process.
There’s a movement in states across the country and in Congress to enact laws that make it easier for patients who don’t respond to the drugs forced to take by insurance companies to bypass or appeal the step therapy protocol. Advocates for the law change say 18 other states have adopted similar guidelines and protocols making it easier for patients to get exceptions.
The Wisconsin bill, heard at a joint hearing of the Assembly and Senate’s health committees, wouldn’t ban step therapy. Instead, it would establish a clear appeals process and detail cases where a step therapy protocol could be bypassed when medically necessary.
Anne Hefty, of Middleton, testified that it took her 13-year-old daughter months to get the medicine she was originally prescribed to treat her rare chromosomal deletion condition. Hefty said the original medication was prescribed in August, but her daughter’s first dose was covered by insurance just last week.
“Once my daughter received the doctor’s original prescription, she dramatically approved,” Hefty said. “No family or patient should have to go through this.”
She said the bill would provide a much-needed exception process
“This legislation will help us to stop fighting with our insurers,” Hefty said.
Similar struggles by other patients and family members, some of whom broke down in tears, were told at the hearing.
The bill is sponsored by Sen. Alberta Darling and Rep. John Nygren, co-chairs of the Legislature’s powerful budget-writing Joint Finance Committee. It has 54 co-sponsors, meaning half of the Legislature is already signed on in support.
The measure is also supported by groups that work with people diagnosed with a variety of chronic diseases, including the AIDS Resource Center of Wisconsin; the American Diabetes Association; the American Lung Association; the Wisconsin Medical Society and the Coalition of Wisconsin Aging Groups.
The Wisconsin Step Therapy Coalition, representing health care providers and people with chronic diseases including arthritis, cancer, mental health issues and addiction, is also working to pass the bill.
Nygren, who is an insurance agent, said he first heard about step therapy during his work leading the state’s efforts to fight opioid and heroin addiction. Nygren said he understands insurance companies wanting to control costs, but “there needs to be logical, common-sense exceptions to this process.”
Nygren said the latest version of the bill was a compromise reached with Wisconsin health insurers. There were no registered opponents to the measure.
Under the bill, exceptions to the step therapy protocol are allowed under certain circumstances. Those include when a doctor provides complete documentation supporting the request or the prescribed drug is expected to be ineffective based on evidence and known characteristics of the patient and the drug regimen. Other exceptions are if the patient previously tried the drug and stopped using it because it failed or the patient is stable on a different prescribed drug.
Additionally, insurers would have three days to grant or deny an exception request, or one day in emergencies. If that deadline isn’t met, the exception is automatically granted.
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