American Society of Plastic Surgeons
For Consumers

Congress: Protect Patients from Step Therapy

As a member of the Alliance of Specialty Medicine, ASPS works to address barriers to specialty care, including barriers experienced by specialty physicians and patients through 'step therapy.' Step therapy requirements create burdensome challenges for clinicians and can limit patients' ability to access the necessary medications prescribed by their physicians.

The Safe Step Act (H.R. 2279/S. 2546) has been introduced in the U.S. Congress to provide patients with basic protections and with fair and reasonable exceptions when they are subject to step therapy. This necessary legislation would require insurers to implement a clear and fair appeals process that is easily accessible on the plan's website and allows step therapy to be bypassed in medically necessary circumstances. The bill would also establish a time frame in which insurers must respond to appeals to ensure that patients can receive appropriate treatment in a timely manner.

The Safe Step Act was a focus of the Alliance of Specialty Medicine's annual advocacy conference this year, during which 150 multispecialty physicians, including ASPS President Lynn Jeffers, MD, MBA, FACS, met with lawmakers on Capitol Hill to educate them about the issue of step therapy and urge them to support this important legislation. During these meetings, physicians highlighted the results of a 2017 Alliance of Specialty Medicine survey, which found that:

  • More than 85 percent have experienced an occasion during which a stable patient was asked to switch from his or her medication by the insurer even though there was no medical reason to do so.
  • Seventy percent reported that their patients were unable to follow recommended treatment plans due to out-of-pocket costs.
  • Nearly 95 percent report needing to change a prescription to a different medication due to delay tactics from insurers related to the original prescription.
  • More than half reported that it took longer than three days to get a patient the proper medication.

A medication step-therapy protocol establishes a specific sequence in which prescription drugs are covered by an insurer. Step-therapy protocols may require patients to try and fail an insurer-preferred medication before covering the physician-prescribed medication. Many insurers have instituted this practice to help control the costs of expensive medications. While this practice may initially reduce insurer costs, it can have devastating health consequences. Patients who are denied first coverage of medications recommended by their physicians can end up with poor health outcomes due to adverse events, which can lead to costly hospitalizations. Appealing step therapy protocols can be very time consuming and can take months to resolve — all while the disease is progressing.