Madison- In Wisconsin, patients often have to "fail" a drug or treatment plan before they can access the medicine their doctor prescribed. This measure, known as "step therapy," is meant to reduce costs by requiring patients to try cheaper alternatives first. Unfortunately, step therapy often ignores a patient's medical history and creates red tape that blocks patients from the best healthcare for them.
On Monday, two Wisconsin lawmakers announced legislation to help patients receive the medicine their doctors prescribed by legislating a clear process to override step therapy protocols. State Senator Alberta Darling (R-River Hills) and State Representative John Nygren (R-Marinette) say their legislation puts patients first.
"It's not cost efficient to require patients to try and fail a drug in order to receive the medicine their doctor actually prescribed," Darling said, "There are clear circumstances when step therapy needs to be overridden, and this bill puts those circumstances into Wisconsin law."
Patients are required to go through step therapy even if they already tried the cheaper drug under a different health plan or when the cheaper alternative interferes with other medications they are currently using. While insurers often have an exemption process from step therapy protocols, it can be unclear and results in unnecessary back and forth between the patient, doctor, and insurance company; all of which delays care. Representative Nygren says step therapy can make people feel like their health care isn't working.
"This bill provides transparency to a confusing process for patients and doctors," Nygren said, "It enhances the doctor patient relationship, expediting necessary care to patients all across Wisconsin."
The legislation creates five common-sense exemptions for step therapy:
- The patient has tried the required prescription drug while under their current or a previous health insurance or health benefit plan, or another prescription drug in the same pharmacologic class or with the same mechanism of action and such prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event.
- The required drug is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug regimen.
- The required prescription drug is not in the best interest of the patient, based on medical necessity.
- The patient is stable on a prescription drug selected by their health care provider for the medical condition under consideration while on their current or previous health insurance or health benefit plan.
- The required prescription drug is contraindicated or will likely cause an adverse reaction by or physical or mental harm to the patient.
The two lawmakers are currently seeking co-sponsors for the bill.