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MADISON, WI — A new law aimed at helping Wisconsin patients navigate insurance-mandated Step Therapy procedures will go into effect this November.

Step therapy, also known Fail First, is an insurance policy protocol that requires the cheapest drug to be prescribed to a patient first, rather than the medicine the doctor originally prescribed.

Wisconsin’s new step therapy law establishes a new set of requirements that health insurance companies have to follow when requiring a patient to try a different and less expensive treatment option than the one prescribed by the patient’s doctor via a Step Therapy process.

The Step Therapy Law requires that all insurers, pharmacy managers or benefit review boards that have a step therapy protocol for prescription medications must meet certain requirements, including:

  • The protocol must be based upon clinical review criteria
  • The process and criteria for selecting and evaluating clinical practice guidelines used to develop the protocol must be posted to the entity’s website
  • The process to request an exception must be clear, accessible, and convenient
  • An appeal process must be established for insureds whose request for an exception is denied.

Gov. Tony Evers signed the Step Therapy bill into law in July 2019. While the Step Therapy Law goes into effect on Nov. 1, plans using a step therapy protocol have until Jan. 1, 2020, to ensure that they comply.

The Office of the Commissioner of Insurance (OCI) issued a bulletin to insurers and interested parties on October 16 summarizing the new law.

Step Therapy Has Its Critics

According to the advocacy website Fail First Hurts, “When a patient has to fail first on a drug before being allowed to take the medication originally prescribed, the patient, physician and public health suffer. By limiting the medication options, both doctors and patients are forced to compromise their treatment decisions in a way that is dangerous, time consuming and more expensive in the long-term.”

The Illinois State Medical Society reportedly fought for reforms in 2018 to make sure there was a step therapy exception review. “ISMS continues to advocate for insurance reforms that put patients first and reduce administrative hassles for physicians,” they wrote in March 2018.

And in Oklahoma, lawmakers pushed for step therapy reform, citing the need to help people get the medications they need in a timely fashion. Under a bill brought forward earlier this year, establishes limits on step therapy including adding procedures to determine medical exemptions.

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