Whereas the goal of controlling costs is admirable, the larger goal of ensuring patients receive the best and most effective treatment for their condition and situation, as recommended by their treating physician, should be the objective of our health care system.
Too often, health insurers require a patient to try and fail on certain less costly drugs before providing coverage for other medications. In other words, the patient must try and fail on Drug A, then try and fail on Drug B before it will cover other similar medications — regardless of what the patient and physician have decided will work best for that patient. This is called step therapy.
The American Diabetes Association supports the passage of Ohio Senate Bill 243 which would implement procedures for health plan development of medication step therapy requirements as well as a process for requesting and granting exceptions to those requirements.
The American Diabetes Association favors the use of a patient-centered approach to guide the choice of pharmacological agents with efficacy, cost, potential side effects, risk, and patient preferences being among the considerations. Yet many health plans impose step therapy requirements for diabetes medications. For example, without any flexibility, if a person with diabetes who has worked with his physician to determine drugs A and B are the most appropriate and effective combination for him enrolls in a new plan with step therapy requirements, he could be required to try and fail on multiple drugs before the plan will cover the drugs he has been taking to successfully manage his diabetes. This could be detrimental to achieving his glycemic goals.
An inflexible step therapy requirement for prescription drugs applied universally to all plan enrollees with diabetes is not in line with a patient-centered approach. Therefore, the Association supports proposals which ensure the patient’s and physician’s preferences are respected in determining coverage for medications.
Ohio Senate Bill 243 takes a thoughtful approach to regulating step therapy protocols to ensure they are clinically sound and the exceptions process is consumer-friendly, which helps ensure a patient-centered approach to treating individuals with diabetes.
Gary Dougherty is the director of State Government Affairs and Advocacy at the American Diabetes Association, based in Powell, Ohio. He can be reached at 1-800-676-4065, ext. 4832.
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