Continued access to a stable treatment can make all the difference for patients with chronic illnesses like arthritis, cancer, diabetes, hepatitis C, HIV/AIDs and more. Interruptions in treatment can lead to disease progression and unnecessary medical expenses like hospitalization or surgery. In rheumatoid arthritis, studies show that delaying treatment can lead to significantly more joint damage than in those patients who receive treatment immediately.

Unfortunately, in Maine these devastating interruptions occur more often than they should because of inappropriate use of an insurance practice called “step therapy” or “fail first.” A fail-first policy requires a patient to try, and fail on, an insurer-preferred medication before covering the medication their doctor prescribes.

I have heard countless stories of patients having their treatments interrupted unnecessarily with harmful consequences. For instance, a patient having to try and fail the same drugs at the beginning of each year under the same insurance plan, though her physician’s favored treatment has worked for years. Or a patient who waited weeks to receive vital treatment because her insurance plan initially required her to try a medication that could have a dangerous reaction with another medication she was taking.

Despite these potential dangers to patients, the use of step therapy is on the rise as insurers use the practice as a cost-saving mechanism. As of 2013, 75 percent of large employers reported offering plans that use step therapy. Yet, some studies have shown that step therapy practices do not save money overall. While the insurance company may save by denying access to prescription medications, that patient may seek vital and necessary care in an expensive hospital or emergency setting. Remember, failing on a medication means that medication is not working for the patient.

In the meantime, a patient’s doctor may attempt to override a fail-first policy through an oftentimes lengthy and cumbersome process before waiting for a response. Doctors have often told our patients that they sometimes need to employ staff solely to process these overrides and the insurer responses. The response could take days or weeks, during which a patient may not receive coverage for their doctor’s recommended treatment.

Last year, lawmakers in Maine rightfully passed legislation to place common-sense guardrails for fail-first practices. The legislation did not ban step therapy, nor did it prevent insurers from requiring patients to try a generic medication if it is equivalent to a brand-name one. Instead, the bill made the process more transparent and easier to manage for both patients and doctors. The legislation allowed a doctor to override a protocol in medically necessary circumstances, such as if the patient has tried and failed on the drug previously or if the patient is stable on their current prescription medication. And it hastened the time frame in which insurers had to respond to appeals.


It was a good compromise and one that a coalition of dozens of patient advocacy groups could get behind. Unfortunately, then-Gov. Paul LePage vetoed the bill last session.

However, this year our coalition is even stronger, and it is our hope that lawmakers will again pass this patient protection legislation and that the new governor, Janet Mills, will sign it into law. That’s why our coalition of health care advocacy organizations and patients will gather in Augusta on Jan. 29 to urge swift passage of this crucial legislation.

At least 21 states have already enacted laws limiting step therapy practices so that patients can get faster access to the medication their doctor knows has the best shot of working. Now is the time for Maine.

Ben Chandhok is senior director of state legislative affairs for the Arthritis Foundation.

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