SB 574/HB 386 Improves Step Therapy, also known as “Fail First,” Protocols, Giving Physicians an Override for – and Patients Transparency into – Insurer Decisions in Treatment of Cancer, MS, Diabetes, Psoriasis, Arthritis & Other Chronic Conditions
Richmond, VA (January 18th, 2018): Fair Health Care VA, a coalition of patient, provider, and health care groups committed to securing access to life-saving treatments for Virginians with chronic conditions, today applauded SB 574/HB 386, introduced by Sen. Bill R. DeSteph, Jr. (R-Virginia Beach) and Del. Glenn Davis (R-Virginia Beach), which is aimed at ensuring patients across Virginia retain access to the treatments they rely on. SB 574/HB 386 improves insurance industry practices known as step therapy, often referred to as fail first, whereby an insurance provider mandates a patient tries and fails on a series of treatments before they can obtain the medication their physician originally prescribed, in an attempt save on short-term costs.
This legislation establishes certain circumstances that require exceptions from fail-first protocols, while increasing transparency within the process for patients and their doctors. The legislation mandates an online process for health care providers to request exceptions and requires a timely turnaround approving or denying such exception, with an explanation of the decision in writing. It also protects patients from undergoing fail first for a treatment they have previously undergone or received an exception from. All of these safeguards are built in without inhibiting an insurers’ ability to use these protocols in a safe, cost-effective and patient-centric way.
“Putting a clear and fair limit on fail first protocols would help Virginians obtain the therapies that keep them stable and out of the hospital while simultaneously helping to control system-wide health care costs. As someone who had a loved one lose insurance coverage for a needed medication, I know first-hand the damage that barriers to insurance such as fail first protocols can have on families in Virginia,” said Delegate Davis, the bill’s primary sponsor in the House of Delegates.
“Far too often, patients across Virginia living with serious, chronic and even life-threatening conditions are kept from the medications they need because of poorly-implemented fail first protocols,” said Donna Guinn Kaufman, a breast cancer survivor and regional field director for the National Patient Advocate Foundation. “SB 574/HB 386 protects patients by providing them an easily-accessible, transparent and accountable process to avoid unnecessary medical approaches and guarantees access to the treatments their doctors have prescribed.”
“I believe that patient care should be decided by a doctor who is sitting across from you, not solely based on a protocol that was developed for the average patient by a committee. This commonsense legislation will ensure that patients receive the quality care they need in a timely manner. Virginians shouldn’t have to fail on a series of medicines or treatments before they get to the one that is right for them,” said Sen. DeSteph, the bill’s primary sponsor in the Senate.
About Fair Health Care VA
Fair Health Care VA is a coalition of more than a dozen patient, provider, and health care groups committed to making sure Virginians living with chronic health conditions have access to the life-saving treatments they need. Fair Health Care VA works to raise awareness and educate patients about their rights when it comes to accessing their medications. The coalition supports policies that protect patient access to the treatments they need.