AZ Legislation Considers Changes to “Step Therapy”
Q&A — Clear-cut Answers to Complicated Questions
“Step therapy” is a protocol in which patients are forced by their insurance plan to try one or a series of lower-priced medications before their plan will cover a drug prescribed by their medical provider. Insurance companies have favored this approach, claiming it drives down costs. However, it often results in patients spending months or even years trying medications that are ineffective or even harmful before they are able to access the treatment their provider had recommended.
With SB1270, the Arizona Legislature is tackling this crucial issue head-on. Will Grove, Resource Facilitation Specialist for the Brain Injury Alliance of Arizona, breaks it down with clear-cut answers to complicated questions.
Will Grove,
Resource Facilitation Specialist for the Brain Injury Alliance of Arizona
AZ Legislation Considers Changes to “Step Therapy”
Q&A — Clear-cut Answers to Complicated Questions
“Step therapy” is a protocol in which patients are forced by their insurance plan to try one or a series of lower-priced medications before their plan will cover a drug prescribed by their medical provider. Insurance companies have favored this approach, claiming it drives down costs. However, it often results in patients spending months or even years trying medications that are ineffective or even harmful before they are able to access the treatment their provider had recommended.
With SB1270, the Arizona Legislature is tackling this crucial issue head-on. Will Grove, Resource Facilitation Specialist for the Brain Injury Alliance of Arizona, breaks it down with clear-cut answers to complicated questions.
Will Grove,
Resource Facilitation Specialist for the Brain Injury Alliance of Arizona
What is the biggest issue with “step therapy”?
WG: When a patient sees their doctor, they trust their physician will recommend a treatment based on the unique complexities of their condition. However, the treatment is often delayed, if not pre-empted, by “step therapy.” This mandated approach utilizes predetermined criteria to force patients to try less expensive drug treatments before moving on to more expensive ones. Too often, even though the doctor knows the less expensive drugs either won’t work or could potentially be harmful, they must go through the trial-and-error process and valuable time is lost.
How does this affect people with brain injuries?
WG: Medication has always been a complex issue for survivors. For instance, two patients may appear to have the same injuries, but can experience wildly different results from the same medication. Therefore, when determining the appropriate treatment for a patient with a brain injury, a neurologist or other provider needs to be able to consider a myriad of variables that simply cannot be accounted for by a “one size fits all” protocol.
What are the risks?
WG: With “step therapy,” patients are forced to fail first on one or more cheaper treatments before getting the appropriate medication to be covered by their insurance. This process can take months or even years, during which time a patient is unable to access the treatment their own doctor says they need. This can result in tremendous hardship and potentially hazardous consequences to the patient’s well-beings.
Is there a middle ground?
WG: The Arizona Senate recently passed Sen. Nancy Barto’s bill, AZ SB1270 to address these problems with common-sense compromises that prioritize the patient’s health and well-being; we urge the House to follow suit. It allows patients to better use the existing medical exemptions offered by their insurer or pharmacy benefit manager to reduce unnecessary hurdles for physicians, administrators, and patients alike.
What are some of these exemptions?
WG: These would include things like if a patient would likely have an adverse reaction to the prescription; or it’s expected to be ineffective; or even if they’d previously used the drug and had discontinued taking it due to experiencing a negligible or negative result.
How would this affect insurance companies?
WG: The bill lays out guidelines to keep insurance companies from dragging their feet when responding to requests. Instead of forcing patients to stick with a drug that’s not working for weeks and months, insurance companies must respond to exemption requests within 72 hours, 24 hours in emergencies. If they don’t respond, the exemption will automatically be granted.
Is Arizona the first state to consider such legislation?
WG: No, dozens of other states have passed similar bills that focus on what the doctor recommends and works best for the patient, not what will save the insurance company the most money. This is critically important for those with brain injury or other disease the requires a delicate level of treatment and care.
It’s clear to me that Arizona should be next.
AZ SB1270 has already passed in the Senate and is currently being considered by the House of Representatives. To express your support for AZ SB1270, reach out to your Representative today. Their contact information is available at azleg.gov.
ABOUT BRAIN INJURY ALLIANCE OF ARIZONA
The Brain Injury Alliance of Arizona (BIAAZ) is the only statewide nonprofit organization dedicated to improving the lives of adults and children with all types of brain injuries through prevention, advocacy, awareness and education. BIAAZ also houses the Arizona Brain Health Resource Center, a collection of educational information and neuro-specific resources for brain injury survivors, caregivers, family members and professionals.
What began in 1983 as a grassroots effort has grown into a strong statewide presence, providing valuable life-long resources and community support for individuals with all types of brain trauma at no charge.
The Brain Injury Alliance of Arizona:
- Works with Congressional Brain Injury Task Force
- Houses Arizona Brain Health Resource Center
- Hosts Statewide Opioid Use Disorder & Cognitive Impairment Workgroup
- Has Statewide Opioid Use Disorder & Cognitive Impairment Response team with peer support, training, and family wraparound services
- Facilitates Brain Health Advisory Council
- Manages statewide Neuro Info-Line: 888-500-9165
