S.6688-A / A.7522 – Step Therapy PA BH Prohibition

The New York Health Plan Association opposes this legislation, S.6688-A /A.7522, which would prohibit the application of step therapy protocols and prior authorization for prescription drugs for the diagnosis and treatment of serious mental health conditions.

Health plans support and promote the use of evidence-based, best practices, utilizing step therapy and prior authorization protocols not simply to reduce costs, but also to assure use of the safest, most effective – and cost effective – medication.  These protocols usually start with the medication that has been available for the longest period of time, with known risks and outcomes, before moving on to newer, and riskier or experimental drugs.  These tools help to protect patients from unnecessary and potentially harmful care and assure that a medication is not co-prescribed with another medication that could have dangerous interactions.  Prohibiting step therapy and prior authorization increases risks to patients, and limits plans’ ability to negotiate better prices for newer and experimental treatment drugs, increasing costs for everyone.

In developing step therapy and prior authorization protocols, health plans’ Pharmacy and Therapeutics committees, which are typically comprised of a cross-section of practicing network physicians, advanced practitioners, pharmacists, and other providers, will review information on the use of inappropriate treatments, practice variation for specific services, the extent to which providers deliver care consistent with evidence, safety concerns, and other relevant factors to determine what services or drugs should be subject to prior authorization.  Health plans regularly review the medical services and prescription drugs that are subject to step therapy or prior authorization and make changes based on new evidence, adherence to recognized standards of care, or, in the case of new and emerging therapies, limited available evidence or safety concerns.  Further, these tools enable health plans to improve care coordination by making sure care management supports are in place as members navigate the system and help with follow-up care and other services the member might need.  Prohibiting step therapy and prior authorization protocols will make it more difficult for health plans to ensure therapies being prescribed are safe, effective, and provide value to members.

Prohibiting step therapy on specific categories of drugs takes away the ability of health plans to ensure the most appropriate drug is utilized and hold pharmaceutical manufacturers accountable for their excessive price increases.  Increased utilization, price inflation, and higher cost drugs continue to drive up prescription drug costs. Drug companies are pushing the limits on prescription drug prices across the board. Six-figure price tags on old and new drugs have become commonplace, specialty drugs and generic drugs see similar pricing jumps, and prices for orphan drugs regularly reach above $300,000. Health plans utilize prior authorization and step therapy to counter these increases and to keep prescription coverage affordable for consumers.

Further, statutory measures already exist to protect members.  For example, Chapter 512 of the Laws of 2016 established strict requirements around step therapy protocols, providing additional protections for patients using step therapy protocols and creating an improved process for timely appeals and overrides of such protocols.  Plans are required to use evidence-based and peer-reviewed clinical criteria that also takes into account the needs of atypical patient populations when establishing step therapy protocols.  The law also provides a standardized appeals process to request an override determination where a prescriber does not believe the drug is in the best interest of the patient.  The process allows for an override where the prescriber demonstrates that the drug is likely to be ineffective based on the patient’s clinical history, or has been tried by the patient already and been ineffective, along with other reasons.

Additionally, current statute requires responses to override requests within 72 hours, or 24 hours in the case of an emergency.  Upon determination that an override should be granted, health plans must authorize immediate coverage for the prescription drug prescribed by the provider.  Moreover, New York has one of the strongest parity oversight programs in the country and the state’s existing mental health parity statute assures that treatment for behavioral health conditions cannot be more restrictive than they are for medical treatments, making this legislation unnecessary.

For all these reasons, we OPPOSE S.6688-A /A.7522.