TRENTON – Legislation that would require certain health insurance providers to cover prescription pain medication was approved Monday by the Assembly.
The bill (A-1832) addresses the shortcomings of “step therapy” or “fail first” policies. Step therapy is the health insurance industry practice of having patients try less-expensive alternative medications before insurance companies will pay for the pain treatment initially prescribed by a doctor.
“Patients dealing with painful conditions should not have to wait for the green light from their insurance companies before they are able to get the medicine prescribed by their doctors as the best treatment,” said Assemblyman John Wisniewski, a sponsor of the bill. “The health of a patient should never come second to cost savings.”
The bill requires certain health insurers, under every policy or contract that provide coverage for outpatient prescription drugs, to provide coverage for prescription drugs used to treat pain in accordance with its provisions. The bill applies to the following: health, hospital and medical service corporations; commercial individual and group health insurers; health maintenance organizations; the State Health Benefits Program; and the School Employees’ Health Benefits Program.
Under the bill, if the insurer or program, in its policy or contract, restricts coverage for medications for the treatment of pain pursuant to a step therapy or fail-first protocol, the following provisions must be adhered to:
- The duration of the step therapy or fail-first protocol must be determined by the prescriber.
- The insurer or program will not require a covered person to try and fail on more than one pain medication before providing coverage to the covered person for the pain medication, including a generic drug product, which has been prescribed.
- Once a covered person has tried and failed on one pain medication, the insurer or program will no longer require prior authorization for coverage of pain medication for the covered person, and the prescriber may write the prescription for the appropriate pain medication. The prescriber is to note in the covered person’s medical record that the person tried and failed on the step therapy or fail-first protocol, and this is to suffice as prior authorization from the insurer or program.
- When the prescriber notes on the prescription that the step therapy or fail-first protocols have been met, a pharmacist may process the prescription without additional communication with the insurer or program.
The bill was approved 51-19-3 by the Assembly and now awaits further consideration by the Senate.
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