Insurance companies would be banned from requiring patients to try cheaper alternative drugs under a bill moving forward in the N.C. House.
Several major insurers require what’s known as “step therapy.” When a doctor prescribes an expensive medication, patients must first try cheaper alternative treatments that target the same ailment. If those drugs don’t work, patients can then receive insurance coverage for the drug their doctor recommends.
Rep. David Lewis, a Dunn Republican who’s sponsoring the bill, said the practice can “delay the quality of care for patients.”
Legislators, he added, have “heard numerous examples of times when individuals got sicker because they did not get the medicine that the doctor asked for them to receive.”
Lewis’ bill faces opposition from the N.C. Chamber, insurance companies and even some fellow Republican legislators. The House Insurance Committee had been scheduled to vote on the bill Wednesday, but the vote was postponed. Bills that get voted down in committees can’t move to the House floor.
Chris Evans, a lobbyist for Blue Cross Blue Shield, said step therapy helps lower drug costs, and about 90 percent of patients in the program stick with the alternative drug.
“Step therapy is a necessary tool to balance out the push for new, higher-price drugs,” she said. “Unrestricted access to drugs would mean that (patients) are constantly steered toward the most expensive drugs on the market.”
Evans said if the bill passes, insurance rate payers can expect their costs to increase by 5 to 10 percent. N.C. Chamber lobbyist Nathan Babcock said that would harm small businesses.
“North Carolina has 57 coverage mandates – that’s the second most in the Southeast,” he said. “Mandates are one of the biggest drivers in health care costs and disproportionately impact small businesses.”
A number of nonprofit groups have called for the ban on step therapy: Arthritis Foundation, National Multiple Sclerosis Society, National Patient Advocate Foundation, National Psoriasis Foundation and U.S. Pain Foundation. They point to the bill’s provision preventing insurers from requiring patients to use opioids that are prone to abuse.
The bill would require insurers to cover opioids that are difficult to crush, snort and inject.
“The time has come that we address the opioid crisis,” said Rep. Greg Murphy, a doctor and Greenville Republican who co-sponsored the bill. “There’s a point where we have to make a decision about paying up front versus paying in the long term.”
But Rep. Gary Pendleton, a Raleigh Republican who owns an insurance business, calls the bill “a sweetheart deal for drug companies.”
“They duped the doctors in it by saying ‘the doctor wants to have his way,’” he said, noting that pharmaceutical companies work hard to market expensive new drugs to doctors. “Every week they’re in there feeding them lunch trying to tell the doctors to sell their product.”
Pendleton noted that the State Health Plan would still be allowed to use step therapy under the bill. Lewis said that exemption was made because the insurance plan for state employees only requires patients to try one drug before getting the one their doctor prefers.
“The bill sponsors didn’t see a need to address an entity that only has one step,” he said.
The House Insurance Committee hasn’t yet scheduled a meeting to vote on the bill.