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New ISMS-Backed Law Provides Exceptions to Insurers' Step Therapy Policies
Posted on: 8/31/2016


We applaud the signing of House Bill 3549, known as the “step therapy” law, which aims to ensure that thousands of Illinois patients have access to the specific medications prescribed by their physician.

The new law puts limits on the insurance industry protocol known as step therapy, or “fail first,” which can require patients to try and fail on a series of medications before being given the medication their physician originally prescribed. Often, insurers will impose step therapy regimens despite evidence that the originally prescribed medication is considered more medically appropriate for the patient’s condition.

House Bill 3549 does not ban step therapy, but rather gives physicians a clearer understanding of specific exceptions that would allow a patient to bypass any step therapy requirement(s).

The ISMS-backed legislation requires that:

  • Insurance companies establish and maintain a medical exceptions process.
  • Insurance companies approve a step therapy exception if the required prescription is contraindicated, the patient had previously tried the required prescription under the patient’s current or previous health insurance plan, or the patient is stable on a prescription drug selected by the physician for the condition in question.
  • Any approvals under the new law are honored for 12 months following the date of approval or until the renewal of the insurance plan.

“This is commonsense legislation that puts the power of prescribing where it should be – in physicians’ hands,” said ISMS President Thomas Anderson, MD. “We also applaud the work done by the Step Therapy Coalition, a group of patient and physician advocacy groups, including ISMS, that worked together to support this important initiative.”

While this new law is not applicable to Medicare, Medicaid or ERISA-protected, self-insured plans, Illinois patients are more likely to get access to the medication their physician prescribed to treat their illness or condition.

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