Baker signs bill curbing step therapy

Insurers limited in forcing patients to try cheaper drugs

A PATIENT who is stable on a medication then switches insurance plans can no longer be kicked off that medication by their insurer, under a new law Gov. Charlie Baker signed Tuesday that limits the insurance practice of “step therapy.” 

Patient advocacy groups have been trying for years to restrict when insurers can use step therapy, or fail-first therapy, in which the insurance company requires a patient to try a less expensive drug before switching to a more expensive one. After years of negotiations between patient advocates and insurance companies over language, a bill was finally passed during informal legislative sessions last month. Baker signed it Tuesday evening over the objections of some in the insurance industry who worried that it would raise costs. 

“This law puts treatment decisions back in the hands of doctors and patients where it belongs,” said Marc Hymovitz, government relations director in Massachusetts for the American Cancer Society Cancer Action Network, who led the coalition pushing for the bill. “It ensures patients will get the necessary medicine in a timely manner.” 

While earlier versions of the bill would have effectively banned step therapy, this bill allows it but creates a number of exemptions, circumstances under which insurers cannot require step therapy. It also requires timely rulings on appeals when patients believe they were incorrectly denied coverage for a drug.  

The new law will eliminate step therapy when someone switches insurers if the patient already tried the less expensive drug, or a similar drug, under a prior insurer or if they are stable on their existing medication. The point of this is to eliminate interruptions in a patient’s treatment solely because they switch insurance plans.  

The bill also includes a broader exemption saying patients cannot be required to try a drug that is unlikely to be effective for them because of clinical characteristics of the patient or characteristics of the drug. This includes cases when trying a drug “will likely cause an adverse reaction in or physical or mental harm” to a patient or if it is “expected to be ineffective based on the known clinical characteristics of the enrollee and the known characteristics of the prescription drug regimen.” 

The policy will go into effect October 1, 2023. 

While the interest groups involved have been negotiating for years, Lora Pellegrini, president and CEO of the Massachusetts Association of Health Plans, said her group was still not happy with the final outcome, which she said in an earlier statement to CommonWealth “impacts the health plans’ ability to lower prescription drug costs and ensure patient safety.” Insurers say step therapy can benefit patients by requiring them to try a drug that has been proven to be effective before switching to a newer, fancier drug that may not be a real improvement.  

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Shira Schoenberg

Reporter, CommonWealth

About Shira Schoenberg

Shira Schoenberg is a reporter at CommonWealth magazine. Shira previously worked for more than seven years at the Springfield Republican/MassLive.com where she covered state politics and elections, covering topics as diverse as the launch of the legal marijuana industry, problems with the state's foster care system and the elections of U.S. Sen. Elizabeth Warren and Gov. Charlie Baker. Shira won the Massachusetts Bar Association's 2018 award for Excellence in Legal Journalism and has had several stories win awards from the New England Newspaper and Press Association. Shira covered the 2012 New Hampshire presidential primary for the Boston Globe. Before that, she worked for the Concord (N.H.) Monitor, where she wrote about state government, City Hall and Barack Obama's 2008 New Hampshire primary campaign. Shira holds a master's degree from Columbia University's Graduate School of Journalism.

About Shira Schoenberg

Shira Schoenberg is a reporter at CommonWealth magazine. Shira previously worked for more than seven years at the Springfield Republican/MassLive.com where she covered state politics and elections, covering topics as diverse as the launch of the legal marijuana industry, problems with the state's foster care system and the elections of U.S. Sen. Elizabeth Warren and Gov. Charlie Baker. Shira won the Massachusetts Bar Association's 2018 award for Excellence in Legal Journalism and has had several stories win awards from the New England Newspaper and Press Association. Shira covered the 2012 New Hampshire presidential primary for the Boston Globe. Before that, she worked for the Concord (N.H.) Monitor, where she wrote about state government, City Hall and Barack Obama's 2008 New Hampshire primary campaign. Shira holds a master's degree from Columbia University's Graduate School of Journalism.

The pharmaceutical industry has generally backed attempts to restrict step therapy, because it makes it easier for doctors to prescribe more expensive medications. The coalition pushing for this bill included numerous patient advocacy groups that advocate on behalf of patients with particular conditions, like the Epilepsy Foundation, American Diabetes Association, and Multiple Sclerosis Association of America. 

The effective date of the legislation has been corrected.