“Step Therapy” or “Fail-First” Healthcare Reform Signed by Governor Brown

by Nazarian for Assembly on September 2, 2016

AB 374 Allows Doctors to Determine Treatment, Not Insurance Companies

(Sherman Oaks, CA) Assemblymember Adrin Nazarian championed a huge win for patients against health insurance companies. “Step therapy” or “fail-first” allows insurance plans to deny coverage of newer, effective medications until patients try older, cheaper options first. AB 374 gives doctors exemption options to override Step Therapy, putting patients first.

“We need to bring balance back to our healthcare system. Patients should not have to ‘fail-first’ to get the medicine they need. Step Therapy Reform provides doctors the opportunity to get the right medicine to their patients,” stated Assemblymember Adrin Nazarian.

AB 374 allows a doctor, based on his/her professional judgment, to request a step therapy override determination from a health plan or insurer, on behalf of a patient.

A request shall be swiftly granted by the health plan/insurer if the prescription drug required by the plan:

  • Is contraindicated or will likely cause an adverse reaction to the patient.
  • Is expected to be ineffective based on the known relevant physical or mental characteristics of the patient and the known characteristics of the prescription drug.
  • Is not in the best interest of the patient, based on medical appropriateness.
  • Will interrupt the patient’s stability on a prescription drug selected by their provider.
  • Has not been approved by the federal Food and Drug Administration for the patient’s condition.

Step therapy is based solely on cost and does not take into consideration patients’ unique needs. AB 374 is an attempt to decrease the common and routine practice of denying patients the prescription medications they need. Anecdotal data shows that plans may require a patient to try up to five different medications before receiving the one prescribed by their provider. Also, the duration of this protocol is left up to the health plan and has been known to last up to 90 days.

AB 374 does not prohibit step therapy protocols; rather, the bill establishes an override process. The bill ensures that a provider’s professional judgment is respected; the provider’s prescription medication, based on the unique situation of a patient, is delivered to the patient. The insurer is not the treating provider and does not know the individual circumstances or pain a particular patient may be undergoing. It is unacceptable for plans to have complete and ultimate control on the medications a patient is allowed to try.

Assemblymember Nazarian added: “Keeping our healthcare costs down is important, but we must not allow cost-cutting to become more important than a patients well-being. AB 374 is important legislation to ensure our doctors are not handcuffed by health plans and insurers.”

Adrin Nazarian represents the 46th Assembly District, serving the San Fernando Valley communities of Hollywood Hills, Lake Balboa, North Hills, North Hollywood, Panorama City, Sherman Oaks, Studio City, Toluca Lake, Valley Glen, Universal City, Van Nuys, and Valley Village.

 

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