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Mass. House passes legislation to reform step therapy protocols

Jessica Giannino
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  Last week the Massachusetts House of Representatives passed (153-0) An Act relative to step therapy and patient safety (H.4929), which limits the use of step therapy protocols in which insurance companies refuse to pay for the prescription drugs prescribed by a patient’s health care provider until the patient first tries cheaper, and oftentimes ineffective, alternatives. The legislation establishes exceptions a patient can use to avoid their insurer’s step therapy protocol and requires both MassHealth and commercial insurers to provide a clear and transparent process for patients and their care team to request an exception. On June 30, the Massachusetts Senate referred the legislation to its Committee on Ways and Means.

  “A top priority of the House is to ensure that every resident of the Commonwealth has access to quality, affordable health care, but controlling costs should never come at the expense of positive patient outcomes,” said House Speaker Ronald Mariano (D-Quincy). “This legislation helps to achieve that goal by ensuring that patients in Massachusetts can circumvent step therapy protocols in instances where the process will result in delayed access to the only adequate medication. I want to thank Chairman John Lawn, as well as all my colleagues in the House, for their commitment to improving our health care system, and for the hard work required to get this done.”

  “This is a great bill for patients,” said the House Chair of the legislature’s Joint Committee on Health Care Financing, Representative John Lawn (D-Watertown). “Under the leadership of Speaker Mariano and in collaboration with my House colleagues, patient advocates, and insurers, this legislation balances the need to manage utilization and control costs of expensive treatments with the moral imperative to protect patients who need life-saving treatments. Thanks to this bill, patients will get the right drug at the right time without delay.”

  “I am both grateful and proud to have been a part of the House passing this legislation; it would have not been possible without the leadership of Speaker Mariano and the teamwork of my colleagues in the House,” said Representative Jessica Giannino (D-Revere). “Insurance companies should not have the ability to gamble or bargain with the health of patients, rather insurers should be held accountable to provide a clear and transparent process for patients and their care team. This legislation will do just that, by limiting the use of step therapy protocols in the Commonwealth.”

  “Massachusetts is the national leader in health care services and delivery. This bill is a critical step in giving doctors and not insurance companies more control over our individual health care treatment plans,” said Representative Jeffrey Turco (D-Winthrop). “I am proud to have joined my colleagues in passing this important patients’ rights bill.”

  The legislation outlines four different circumstances that trigger the patient exception process:

  1. The required treatment will harm the patient.

  2. The required treatment is expected to be ineffective.

  3. The patient previously tried the required treatment, or similar treatment, and it was ineffective or harmed the patient.

  4. The patient is stable on a current treatment and switching treatments will harm the patient.

  Additional highlights of the legislation:

  •  A requirement that MassHealth and commercial insurers adopt a “continuity of coverage” policy to ensure patients do not experience any delay in accessing a treatment when requesting a step therapy exemption.
  •  A requirement that MassHealth and commercial insurers approve or deny a step therapy exemption request within three business days, or within one business day if a delay would cause harm to the patient.
  •  A requirement that commercial carriers annually report data related to step therapy exemption requests and related coverage determinations to the Massachusetts Division of Insurance.

  ·  The creation of a commission on step therapy protocols tasked with studying, assessing and biannually reporting on the implementation of step therapy process reforms made in this legislation.

Turco headshot_Cropped-2
Jeffrey Turco
State Representative

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