State Senate Passes Bill to Limit Use of Step Therapy

BOSTON — Last week, the Massachusetts state Senate passed legislation to limit the use of step therapy, or ‘fail-first’ protocols that too often direct patients to cheaper medications rather than those more suitable to treat their condition, the bill’s proponents say.

The bill gives healthcare providers more leverage in determining the most effective treatment options for patients, saving patients from expensive and painful regimens on medications they know to be ineffective or harmful.

“Doctors should be able to prescribe medications to patients that in their best medical judgement lead to healthier outcomes. Providers shouldn’t have to negotiate the pitfalls of fail-first protocols when following what they believe to be the most effective plan of care for their patients,” state Sen. Eric Lesser said. “This bill is a significant step in the right direction, returning power to patients and their doctors.”

Step therapy serves as a cost-saving mechanism that can limit a patient’s ability to access the medication that is most suitable for treating their condition. Insurers that utilize step-therapy protocols require medical providers to prescribe lower-cost medications to patients first, and only grant approval for alternative medications when the cheaper options have failed to improve a patient’s condition. In practice, this results in insurers effectively choosing medications for the patient, even in cases where their providers have recommended an alternative. When patients change insurers, they are often forced to start at the beginning of the step-therapy protocol again, which results in wasteful healthcare expenditures, lost time for patients, and potentially devastating healthcare impacts on the patient, according to the bill’s supporters.

The bill aims to establish guardrails to protect patients in circumstances in which step-therapy protocols are counterproductive or harmful. It would require MassHealth and private insurers to grant exemptions to step-therapy protocols in cases where the protocol-required cost-effective drug is likely to cause harm, is expected to be ineffective, has been tried by the patient previously, is not in the best interest of the patient, or, when adopting it in concert with the patient’s existing medications, would cause harm. Upon granting exemptions, MassHealth and private insurers would be required to provide coverage for the drug recommended by the patient’s provider.

The bill now moves to the state House of Representatives for consideration. If passed, Massachusetts would join 28 other states in curbing step-therapy practices.