ACS CAN Releases Examples of Step Therapy Policies by New Jersey Regulated Health Plans

FOR MORE INFORMATION                                                
Marc Kaplan
American Cancer Society Cancer Action Network
(518) 796-1038
[email protected]

TRENTON, NJ – May 10, 2021 – The American Cancer Society Cancer Action Network (ACS CAN) has released a list of examples  (attached) of step therapy policies by New Jersey regulated health insurance plans. The examples are an individual look at each of these plans and details how the practice of step therapy works in New Jersey.

Step therapy policies, also known as fail first, are used by health insurers to force patients to try medications that insurance companies choose, requiring the patient to “fail first” before gaining access to the medicine originally prescribed by their health care provider. This insurance practice undermines a doctor’s ability to appropriately treat patients with serious diseases and can greatly impede patient recovery.

In January 2019, ACS CAN sponsored a nationwide survey of cancer patients, caregivers, and doctors regarding insurance utilization management techniques like step therapy. The survey results detail the negative effects of these policies.

Patients and caregivers reported that these policies delayed their care, increased their stress and frustration, contributed to worse outcomes and cost them more out of pocket. Doctors reported that these requirements made it harder for them to treat patients, delayed treatment and were time-consuming.

Legislation (S3051/A4815) is currently being considered by state lawmakers to reform the practice of step therapy in New Jersey. This legislation would ensure that when step therapy is used in New Jersey it is safe for patients, clinically grounded, and transparent to patients and health care providers. The legislation passed overwhelmingly in the General Assembly in March and has 18 sponsors in the Senate. It is pending a vote in the Senate Commerce Committee.

Along with the examples, ACS CAN delivered a letter to state lawmakers outlining the practice of step therapy in New Jersey and requesting their support for the step therapy reform legislation.

SEE THE COMPLETE EXAMPLES HERE.

Below is a summary of the New Jersey regulated commercial plans in the individual market with step therapy protocols.

Insurer A requires patients to complete a prior authorization form that indicates there is a step therapy requirement for antineoplastics (also called anticancer, chemotherapy, chemo, cytotoxic). On the form patients are asked in the Patient Treatment History section if the patient had an inadequate response to or inability to tolerate other medications.

Insurer B requires patients to complete a prior authorization form that indicates there is a step therapy requirement for many different types of self-administered oncology drugs. The form asks if the patient has had an inadequate response to other oncology drugs.

Insurer C states in their clinical guidelines on their main website that for all commercial plans “Approval for non-preferred medications may require that the member has a contraindication to the preferred medication(s); has tried and failed the preferred medication(s); had an inadequate response to the preferred medication(s); or had an intolerable adverse event with the preferred medication(s).” This is the definition of step therapy.

Many small group plans regulated by New Jersey also require step therapy before approving certain drugs. Some examples include:

Insurer A requires patients to complete a prior authorization form that indicates there is a step therapy requirement for most Select plans. For example, the prior authorization form for immune modulating drugs asks for every drug type if the patient has had an insufficient response to preferred drugs.

Insurer B explicitly states that their formulary applies to both individual and group plans. This would mean that the step therapy requirement identified in the individual market would also apply to the small group market.

Insurer C offers off-exchange Small Group Plans.  We chose a bronze plan at random and found that the corresponding “Summary of Benefits and Coverage” document indicates that “Preauthorization/step therapy may be required. If you don't get preauthorization payment for care may be denied.” The prior authorization form used across all Insurer C plans has clear evidence of step therapy.

About ACS CAN at 20 

The American Cancer Society Cancer Action Network (ACS CAN) makes cancer a top priority for policymakers at every level of government. ACS CAN empowers volunteers across the country to make their voices heard to influence evidence-based public policy change that saves lives. We believe everyone should have a fair and just opportunity to prevent, find, treat, and survive cancer. Since 2001, as the American Cancer Society’s nonprofit, nonpartisan advocacy affiliate, ACS CAN has successfully advocated for billions of dollars in cancer research funding, expanded access to quality affordable health care, and made workplaces, including restaurants and bars, smoke-free. As we mark our 20th anniversary, we’re more determined than ever to stand together with our volunteers and save more lives from cancer. Join the fight by visiting www.fightcancer.org.