SB 746 – Health Insurance - Step Therapy or Fail-First Protocol
Senate Finance Committee
Senator Thomas M. Middleton, Chair
February 27, 2013
Position: Support
As a grassroots organization representing families and individuals living with mental illness,
NAMI Maryland is dedicated to improving the lives of all those affected by mental illness,
including making sure that individuals simultaneously combatting co-occurring disorders
receive effective and efficient treatment. Accordingly, NAMI Maryland strongly supports
limiting the duration of a step therapy (also known as “fail first”) imposed by a specified
insurer, nonprofit health service plan, or health maintenance organization, and requiring
those entities to allow a prescriber of a covered prescription drug or device to have prompt
access to a process to override the step therapy or fail-first protocol.
For many of our members, insurance discrimination continues to be a major barrier to
improving the health and well-being of not only the consumer, but their families as well. As
such, with any effort to reform step therapy (also known as “fail first”) insurance barriers,
physicians and health care practitioners must retain the ultimate responsibility for patient
treatment decisions regarding all medical issues, including what services, procedures, and
medications are most appropriate for individual patients on a case-by-case basis. Further,
clinical judgment and patient choice must always take precedence over payer cost
considerations in decisions about individual care and decisions related to patient care must
always rest with the patient's physician or health care practitioner.
As it stands now, Maryland insurers have inserted themselves into the provider-patient
relationship and are making decisions about how to treat patients, all while making Maryland
patients jump through unnecessary hoops. Patients are currently required to fail certain step
therapy protocols for a potentially indefinite amount of time. Step therapy policies don't
allow for clinical judgment, unnecessarily prolong ineffective treatment, and prevent patients
from immediately starting the treatment their practitioners think is best. They also can mean
unnecessary suffering leading, more costly and intensive treatment, and in some cases
suicide.
A May 2010 survey by MedChi found that, for 95% of Maryland physicians, health insurer
protocols had a "somewhat" or "very negative" impact on the doctor's ability to effectively
treat patients, and 88.5% of physicians identified insurance barriers such as pre-approval,
step-therapy, drug switching and other protocols as "burdensome," "very burdensome," or as
a "major hassle." Similarly, in informal surveys of NAMI Maryland members, the
overwhelming majority cited obstacles from insurers in seeking effective program treatments
or regimes as a key barrier. Delayed access to the right medication can often mean not only
delayed recovery from mental health issues, but ongoing or even irreversible harm.
Inasmuch, NAMI Maryland supports legislation that amends insurance law to regulate step
therapy policies that:




Do not require the patient to exhaust the least expensive or non-FDA labeled
treatment option;
Gives practitioners the ability to override the step therapy protocol under specific
circumstances when the practitioner believes it is in the best interest of the patient;
Establish guidelines to ensure practitioners have an expeditious process to override
step therapy under certain circumstances if the practitioners believe it is medically in
the best interest of the patient; and
Limit the time period a patient can be subjected to step therapy to the period deemed
necessary by a prescribing practitioner to determine the treatment's clinical
effectiveness, or a period no longer than 30 days.
Unequal, disjointed or cost-based behavioral health coverage by various insurers, just as with
the "separate but equal" policy during school desegregation of the 1950’s and 60’s, can never
be truly equal or effective. Based upon this understanding, we strongly urge Senate Finance
Committee Members to SUPPORT SB 746.
NAMI Maryland is a statewide organization, with thirteen local affiliates, dedicated to
advocacy for and education of persons with mental illnesses, their families and the
community. NAMI Maryland advocates for the public and private resources needed to
assure the availability, accessibility and quality of comprehensive mental health services
throughout the state.
2