General Assembly Passes Step Therapy Bill
House Bill 63 passed the Georgia General Assembly and has been sent to the governor. If he signs it, the bill will take effect on January 1, 2020. Hemophilia of Georgia, along with our partners in the Rx in Reach GA Coalition, advocated for passage of the bill. This important legislation puts restrictions on how health insurance companies can impose “step therapy” for drugs.
“Step therapy” refers to a requirement by a health insurance plan that a patient try and fail on one or more drugs before the plan will cover the drug that was originally prescribed for the patient. It puts the insurer in charge of deciding what drug is best for a patient, not the physician. Currently there is little a patient can do in Georgia to force the insurer to allow the drug that the doctor has prescribed.
HB 63 would help change that situation by giving doctors ways to request an “exception” to a step-therapy requirement. Under the new law, a doctor can submit information to the health insurance company to show that the prescribed drug should be given to the patient and not the one chosen by the insurer. The documentation needs to show that the insurer’s drug:
- Is contraindicated or will cause an adverse reaction or physical or mental harm to the patient;
- Is expected to be ineffective based on the known clinical condition of the patient and the known characteristics of the drug; or
- Has been tried by the patient – or the patient has tried a similar drug -- and it didn’t work or it caused an adverse event.
HB 63 also allows the doctor to protest a switch in drugs (the insurance company telling a patient they must use another medication) if the patient is currently doing well on a medication and the switch is expected to harm to the patient.
Once a doctor requests an exception, the insurance company must respond within two business days (within 24 hours if it is an urgent health situation).
It is important to note that this law doesn’t prohibit insurers from requiring patients to try a generic version of a drug. Generic drugs have the same active ingredient as a brand-name drug. This law also doesn’t apply to the Medicaid or PeachCare for Kids programs.
Please call Governor Kemp’s office at 404-656-1776 and ask him to sign HB 63, The Step-Therapy Bill.