Step Therapy Reform
SB 680 (HB 1464) addresses a core patient access concern: step-therapy, or requirements by insurance plans to make patients try and “fail-first” on other medications before covering the medication prescribed by a patient’s doctors. Step-therapy and fail-first create barriers for patients to get the right medicines in a timely manner. SB 680 amended current law relating to step therapy protocols required by a health benefit plan in connection with prescription drug coverage and ensures step therapy protocols are reasonable and transparent for Texans and their health care providers. The new law also categorizes step therapy exemption denials as adverse determinations and allows patients to access an expedited external review. From a patient perspective, the new law clarifies certain circumstances when a provider can seek to override a particular step therapy protocol based on an individual patient’s medical needs and history. Four other states have enacted similar legislation.
Single, Consistent Formulary for Medicaid Prescription Drugs
HB 1917 extends the state’s current Vendor Drug Program (VDP) for Texas Medicaid, providing for a single formulary for all patients. The bill protects patients by providing a consistent, single formulary, reviewed and developed by medical professionals, for prescription medications and, in a transparent process in which stakeholders have a voice, guards against shifting Medicaid’s prescription drug program into multiple managed care organizations (MCOs) and pharmacy benefit managers (PBMs).
Medication Synchronization for Improved Patient Adherence
HB 1296 (SB 697) helps improve patient adherence to prescribed medications by coordinating the refill dates for all of a patient’s chronic prescription medicines so they can be picked up on the same date each month. With the passage of HB 1296, patients’ and caregivers’ lives are simplified by eliminating multiple trips to the pharmacy each month and by reducing confusion over when a prescription is due to be refilled.
Non-Medical Switching - DID NOT PASS
HB 2882 (SB 1967) would have addressed an increasingly common and unfortunate practice of “non-medical switching,” when an insurance company changes the terms of coverage or costs of a medication for a stable patient (e.g., a patient who, in consultation with their doctor, has found the best medication to control or manage their symptoms). Non-medical switching can take the form of placing a medication on a higher-tier, with a larger co-pay or lowering maximum coverage amounts for prescription medications, limiting how much you can receive. Simply put, non-medical switching leaves patients without access to doctor-prescribed medications that are most effective for an individual patient. HB 2882 was left pending in House Insurance Committee, but we anticipate this issue will surface again in the 86th Legislative Session (2019).