Senate Passes Bill to Limit Use of Step Therapy

On July 30, with the support of Senator Jason Lewis, the Massachusetts State Senate passed legislation to limit the use of step therapy, or ‘fail-first’ protocols that too often direct patients to cheaper medications rather than those more suitable to treat their conditions. An Act relative to step therapy and patient safety gives doctors more discretion in determining the most effective treatment options for their patients, saving patients expensive and painful regimens on medications they know to be ineffective or even harmful.

This legislation builds on the state Senate’s ongoing commitment to creating a more affordable, accessible, and patient-centered health care system for everyone in the Commonwealth. Earlier this legislative session, the Senate passed legislation to contain rising prescription drug costs, increase access to affordable mental health services, and expand access to telehealth even after the COVID-19 pandemic is behind us.

“This legislation puts medical decisions where they belong: in the hands of patients and their doctors, instead of letting health insurers dictate treatment protocols” said Senator Jason Lewis. “Especially for people living with a variety of chronic illnesses, step therapy can be harmful to their health, and I’m very grateful to advocates like Sammantha Dorazio who have long pushed for this legislation.”

“Going through step therapy was a real-life nightmare,” said Sammantha Dorazio, Malden resident and arthritis patient advocate. “I cried tears of joy when I got the news that the step therapy bill passed. This is a huge win for the arthritis community.”

Step therapy serves as a cost-saving mechanism that can limit a patient’s ability to access the medication that is most suitable for treating their condition. Insurers that utilize step therapy protocols require medical providers to prescribe lower-cost medications to patients first, and only grant approval for alternative medications when the cheaper options have failed to improve a patient’s condition. In practice, this results in insurers effectively choosing medications for the patient, even in cases where their doctors have recommended an alternative. When patients change insurers, they are often forced to start at the beginning of the step therapy protocol again, which results in wasteful health care expenditures, lost time for patients, and potentially devastating health care impacts on the patient.

Step therapy is not limited to specific disease states. It affects patients across the healthcare spectrum, with particularly dramatic impacts on the Allergy and Asthma, Antipsychotic, Arthritis, Cancer, Coronary Artery, Depression, Diabetes, HIV/AIDS, Multiple Sclerosis, and Parkinson’s patient communities.

The bill would establish guardrails to protect patients in circumstances in which following step therapy protocols are counterproductive or harmful. It would require MassHealth and private insurers to grant exemptions to step therapy protocols in cases where the protocol-required cost-effective drug is likely to cause harm, is expected to be ineffective, has been tried by the patient previously, is not in the best interest of the patient, or adopting it in concert with the patient’s existing medications would cause harm. Upon granting exemptions, MassHealth and private insurers would be required to provide coverage for the drug recommended by the patient’s provider.

If passed into law, Massachusetts would join 28 other states in curbing harmful step therapy practices. The bill now moves to the House of Representatives.