June 5, 2017
The Legislature enacted House File 233 and the Governor signed the bill into law on Friday, May 12. This bill requires health insurance companies to make changes to their step therapy protocols. Under current law, a patient may be required to try, and then fail on lower-cost or older drugs selected by their health plan before coverage is granted for the drug prescribed by the patient’s health care provider. These policies can vary widely based on the prescription and the insurance company’s policy. These protocols limit a health care provider’s ability to tailor care to individual patient needs. For patients living with serious or chronic illnesses, prolonging ineffective treatment may result in possible irreversible progression of disease, loss of function, and adverse effects. This may ultimately lead to increases in unnecessary health care costs associated with additional provider visits, ER visits, hospitalizations and other costs.
The bill requires the protocols are based on widely-accepted clinical guidelines; the exceptions process is transparent and accessible to patients and health care providers; provisions that enable health care providers and patients to override a health plan’s protocols when it is medically appropriate for a patient. The bill gives greater power to physicians and patients who are trying to gain access to certain procedures and/or pharmacy benefits. The Bill provides that when a step therapy protocol is in use, the person participating in a health benefit plan or the person’s prescribing health care professional must have access to a clear, readily accessible “step therapy override exception,” which authorizes the expedited coverage of a prescription drug selected by the prescribing health care professional, based on the review of the exception request along with supporting rational and documentation. It is important to note that the bill specifically excludes the three major managed care organizations that are contracted with the state of Iowa to provide Medicaid-related services.