New step therapy law aims to help get patients easier access to drugs prescribed by their doctors

Deb Constien thinks back to a time nearly two decades ago when she wasted time and money trying to get a prescription that she needed.

Constien, who lives in Sun Prairie, was diagnosed at age 13 with rheumatoid arthritis. About 18 years ago, her arthritis medication caused damage to her stomach, so her doctor prescribed a medication that seemed to do the trick. But it was short-lived.

“The insurance company decided that I might have had some ‘healing’ to my stomach, so they wanted me to go back to square one, which is medications that I had already failed. They wanted me to restart all over again,” she said.

She had to have tests done and try other medications before being allowed to go back to the drug she had been using.

“It was so frustrating,” she said. “Why take somebody off a stable medication and have them go back to the beginning on stuff that I had already failed?”

Constien was “stepped,” or in other words, her insurance company used the step therapy protocol. It’s a practice health insurance companies use to help control the costs and risks of prescription drugs. Patients often have to try cheaper, generic and less risky drugs before their insurance companies will cover the drug prescribed by the patient’s doctor.

But the Step Therapy Law, which went into effect Friday in Wisconsin, reforms the protocol and provides new regulations for health insurance companies to follow. Gov. Tony Evers signed a step therapy bill into law in July after it was passed by both chambers of the Legislature earlier this year.

Patients are now able to ask for exceptions, and insurance companies would have to grant or deny the requests within 72 hours or 24 hours in emergency circumstances.

Thad Schumacher, owner of Fitchburg Family Pharmacy, said he hopes the new law will help him provide better care for patients.

“When we have a step therapy issue with regard to medication at the pharmacy level here, what it really is is us waiting for the insurance company or the pharmacy benefit manager to process payment and allow us to be paid for the medication so we can give it out,” Schumacher explained.

A downside of the law, he said, is it could increase costs in the health care industry. Schumacher pointed out that more expensive medications usually mean the patient is responsible for paying money, so it is “beneficial” for patients to use generic versions of drugs if possible.

State law now requires that insurers have clear and accessible information about the process to request exemptions under the step therapy protocol. Insurers must also establish an appeal process for patients whose requests are denied.

The Step Therapy Law goes into effect Nov. 1, but insurance companies have until Jan. 1, 2020, to make sure they comply with the new law.

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