Safe Step Act (S. 464 / H.R. 2163) creates a clear, timely and transparent process for a patient or physician to request an exception to step therapy protocols in certain situations. Step therapy is a tactic used by insurance companies that requires a patient to try and fail on their preferred medications before covering the therapy prescribed by their health care provider.
The legislation outlines situations in which a group health plan must grant an exception to “fail first” protocols, including if an application clearly demonstrates:
- Patient already tried and failed on the required drug
- Required drug is reasonably expected to be ineffective
- Required drug will cause harm to the patient
- Required drug will prevent a patient from working or fulfilling daily activities
- Patient is stable on his/her current medication
The bill also requires that a request for an exception to step therapy be answered by the insurance company within three days, and in less than 24 hours if the patient’s life is at risk.
- Establishing an electronic prior authorization (ePA) program and requiring eMA plans to adopt ePA capabilities;
- Requiring the Secretary of Health and Human Services to establish a list of items and services eligible for real-time decisions under an MA ePA program;
- Standardizing and streamlining the prior authorization process for routinely approved items and services;
- Ensuring prior authorization requests are reviewed by qualified medical personnel;
- Increasing transparency around MA prior authorization and its use; and
- Protecting beneficiaries from any disruptions in care due to prior authorization requirements as they transition between MA plans.
The Safe Step Act and Improving Seniors’ Timely Access to Care Act attracted significant bipartisan support in the past. Congress must be compelled to pass both bills this year. However, advancing these bills requires a strong show of support by lawmakers through their cosponsorship of the legislation. The more cosponsors a bill has, the more likely it is to receive a vote and is why ASGE is asking for your help.
Lawmakers need to hear from you, their constituents, about why the Safe Step Act and the Improving Seniors’ Timely Access to Care Act are important to you and your patients.