(TRENTON) – An Assembly panel has approved legislation sponsored by Assembly Democrats Herb Conaway, Jr., M.D. (D-Burlington) and Daniel Benson (D-Mercer/Middlesex) that would ease access to prescription pain medication for patients who need it by requiring certain health insurance providers to cover prescription pain medication.
The bill, which was approved by the Assembly Appropriations Committee, last month, addresses the shortcomings of “step therapy” or “fail first” policies. Step therapy is the health insurance industry practice of having patients try less-expensive alternative medications before insurance companies will pay for the pain treatment initially prescribed by a doctor.
“The purpose of step therapy is to control costs and minimize risks, but for some patients, this method does not work,” said Conaway. “To deny coverage for pain medication that has been prescribed by a doctor as the most effective way to alleviate a patient’s pain is cruel. This bill puts the patient’s well-being first and ensures they are able to get the medication they need when they need it.”
“Telling patients that they cannot get the best pain medication available until they try a series of cheaper versions disregards the advice of their doctors and denies patients immediate relief,” said Benson. “Treatment decisions should be made by physicians, not insurance companies.”
The bill (A-1832) requires certain health insurers, under every policy or contract that provide coverage for outpatient prescription drugs, to provide coverage for prescription drugs used to treat pain in accordance with its provisions. The bill applies to the following: health, hospital and medical service corporations; commercial individual and group health insurers; health maintenance organizations; the State Health Benefits Program; and the School Employees’ Health Benefits Program.
Under the bill, if the insurer or program, in its policy or contract, restricts coverage for medications for the treatment of pain pursuant to a step therapy or fail-first protocol, the following provisions must be adhered to:
- The duration of the step therapy or fail-first protocol must be determined by the prescriber.
- The insurer or program will not require a covered person to try and fail on more than one pain medication before providing coverage to the covered person for the pain medication, including a generic drug product, which has been prescribed.
- Once a covered person has tried and failed on one pain medication, the insurer or program will no longer require prior authorization for coverage of pain medication for the covered person, and the prescriber may write the prescription for the appropriate pain medication. The prescriber is to note in the covered person’s medical record that the person tried and failed on the step therapy or fail-first protocol, and this is to suffice as prior authorization from the insurer or program.
- When the prescriber notes on the prescription that the step therapy or fail-first protocols have been met, a pharmacist may process the prescription without additional communication with the insurer or program.