National Headache Foundation Stands Against Step Therapy
The National Headache Foundation (NHF) opposes the use of step therapy requirements that hinder medically appropriate access to medicine for headache disorders, migraine disease and other conditions.
Step therapy is a “utilization management” method used by insurance companies. Patients are required to try – and fail – a number of medicines or regimen before another can be covered. The approach is typically used to reduce plan costs by steering patients toward less expensive treatment.
Members of the NHF patient community need medicines to treat headache disorders, migraine disease and other related conditions. Often, patients have to work closely with their healthcare practitioners to identify the right medicine for them. NHF opposes step therapy requirements, in public or private insurance, which make it harder to access to the safest and most effective medicine as chosen by the patient and their healthcare practitioner.
Federal Engagement
HR 2630/S 652 Safe Step Act—As of 10/1/2024: Senate: 45 cosponsors; House; 233 cosponsors.
Support patient protections for the approximately 100 million individuals with self-insured employer plans by advocating for federal step therapy reform.
Step therapy, sometimes referred to as ‘fail first’ or ‘step protocol,’ has severe consequences for patients who need care. Step therapy is a prior authorization practice where insurers require approval before covering a treatment or medication and where insurers implement tiered treatment pathways for medical conditions.
The Safe Step Act is federal legislation that is modeled after the state-based step therapy exception laws. The Safe Step Act would apply to employer plans and would:
- Ensure that plans offer patients and their medical professionals a step therapy exception request process.
- Require plans to respond to an exception request within 24-72 hours.
- Establish circumstances when a patient should be granted an exception by their health plan.
State Engagement
Step Therapy Protections
https://steptherapy.com/step-therapy-legislation-by-state/
We recommend that anyone with a commercial plan, including an employer plan, use the step therapy exception request forms provided in the map above if they need to seek a step therapy exception.
Generally, these state laws apply to the following plans:
- Individual and small group plans (i.e. Exchange plans)
- Fully insured employer plans
In addition, the state information in the map above will indicate if the step therapy protections apply to the state’s Medicaid program. While only a few states have implemented step therapy guardrails on their Medicaid programs through legislation, many more have put patient protections in place through agency-level regulation. Please reach out to your state’s Medicaid program for more information about step therapy in your state if you still have questions after consulting our map.
Michigan
On July 19, 2024, Aimed Alliance and ten other advocacy organizations (including the National Headache Foundation) sent a letter to Governor Hochul urging her to swiftly sign legislation that would create new and improved step-therapy guardrails for New York consumers. Specifically, A.901(a)/S.1267(a) would prohibit individuals from trying and failing on off-label treatments; limit steps to no more than two in a therapeutic category; and provide greater clarity on timelines for trying and failing on a medication.
