As we ring in the new year, we celebrate a major step therapy legislative win in New York! An increasing number of health insurers around the country are utilizing fail first or step therapy practices that require patients to try and fail one or more formulary medications before providing coverage for the originally prescribed non-formulary medication. Rather than taking into account the needs of the individual patient, insurers are determining drug sequences based on cost. These practices can vary wildly insurer to insurer with no consistency on how to establish or apply these fail first protocols.
As a result, step therapy practices can lead to delays in access to the medications that offer the greatest potential medical benefit to people with arthritis. Since arthritis is a chronic and degenerative disease, delays in treatment can worsen disease progression and even cause permanent damage and disability. Additionally, required fail first drugs may cause adverse reactions or complications to the patient due to side effects.
Legislation (S3419C) signed on New Year’s Eve by New York Governor Andrew Cuomo includes two basic patient protections that will improve the safety and efficacy of step therapy protocols. First, it requires that clinical review criteria, used by an insurer to establish fail first protocols, is based on science and evidence-based clinical practice guidelines and not exclusively driven by cost. Second, the bill requires a clear and expedient process that can be used by physicians and other prescribers to request an override of a fail first protocol.
Many Arthritis Foundation Ambassadors, including Erin O’Rourke, played key roles in passage of the bill sponsored by Republican Senator Catharine Young and Democratic Assemblyman Matthew Titone. Erin was featured in a story on local network television station Fios Long Island in November. In the interview, she explained how step therapy insurance practices can impact patient’s lives and employment, saying, “If you switch a job, you have to start all over again.”
“This is a significant victory for the New York arthritis community,” said Sandie Preiss, national vice president for the Foundation’s Advocacy & Access program. “This legislation is crucial to protect those patients facing severe illness by ensuring timely access to the right medications. It’s the result of tireless work by our Advocates and continuous support from New York’s legislators and Governor Cuomo.”
This legislation will help the nearly four million New Yorkers who live with doctor-diagnosed arthritis receive timely access to the correct medication. Thanks are due to many other Advocates and Ambassadors who worked for passage of the bill by sending letters, making phone calls and submitting videos through social media to the Governor’s office urging him to sign this bill.
These important victories don’t happen without participation and support from people who are affected by arthritis – people like you! Get involved by attending the 2017 Advocacy Summit, March 6-7, in Washington, DC.