AUGUSTA — A growing number of states have passed laws to help patients get the medication they want despite the cost, including Maine under a law recently signed by Democratic Gov. Janet Mills.
The new law, which mirrors similar legislation twice vetoed by former Republican Gov. Paul LePage, takes effect in mid-September. Georgia, Washington and Oklahoma passed similar bills this year, according to the Arthritis Foundation, which calls Maine’s law one of the nation’s “strongest.”
Currently, a policy known as “step therapy” allows insurers to require patients to try the least risky or most cost-effective drugs and progress to other medications only if necessary.
Supporters, which include patient rights groups, say Maine’s new law would bring transparency and flexibility to that process. Advocates say it’s dangerous to force patients with chronic physical or mental illnesses to “fail first” and sometimes face emergency room visits and hospitalizations before receiving medication originally prescribed by their physician.
Existing Maine law includes some protections for patients who want to appeal such decisions. Health plans have two business days – or 24 hours for urgent requests – to make a decision on such appeals once they receive all the information they need.
But it’s a cumbersome process, according to patient Lori Schnieders of Cutler, who has autoimmune hepatitis and travels over four hours to receive treatment for rheumatoid arthritis she has battled for 40 years. She called step therapy a costly waste of time for providers that amounts to “torture” for some patients, particularly those not well-versed in insurance procedures.
“They put me through the process of: ‘Have you tried this, have you tried that, let’s try this,’ ” said Schnieders, a child psychology professor. “Because the medication that I’m on frankly is quite expensive.”
Her insurer twice made her try a new medication that caused severe allergic reactions, she said. Now each January, she said, she has to justify why she wants to stay on her medication instead of switching to other drugs.
“If I’m not having severe flare-ups with my arthritis, then why not leave me on the medication that’s worked for nine years?” She said. “Why keep trying to change it?”
Maine’s new law will grant appeals or exceptions automatically if insurers don’t decide in 48 hours, and within 24 hours for “exigent circumstances.”
Schnieders said she is excited that Maine’s law will require step therapy decisions to be based on clinical practice guidelines and ensure physicians can request exceptions. The law also includes explicit exceptions for patients who have already tried the required prescription drug.
Insurers could still require enrollees to try a generic drug before covering an equivalent brand-name prescription drug.
“It certainly doesn’t ban step therapy,” said Ben Chandhok, spokesman for the Arthritis Foundation. “We just want to make in certain specific circumstances, they can navigate that.”
But insurers and pharmacy benefit managers argue that Maine’s law will hurt efforts to both lower prescription drug costs and protect patients from costly or less-established therapies. Such critics warn that Maine’s law will raise premiums and out-of-pocket costs, and say doctors are too quick to prescribe new drugs pushed by pharmaceutical companies.
“Many drugs have harmful side effects or interact adversely with other medications,” April Alexander, Pharmaceutical Care Management Association assistant vice president, told lawmakers in written testimony this spring. “Step therapy encourages trying safer, alternative therapies first.”
Such critics took particular issue with the part of the law providing exceptions from step therapy for patients who are “stable” on a prescription drug selected by a provider.
Maine’s bill drew lobbyists representing the nation’s biggest insurers along with major pharmaceutical manufacturers.
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