Insurance Practice That Requires Clients To Take Drugs Other Than The Ones Prescribed Would Be Limited Under Bill

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February 5, 2021 - 12:05pm

An insurance industry practice that allows providers the authority to require clients to take generic medications before more expensive, prescribed ones, could be curtailed under the proposed legislation.  

If approved, the bill would give clear definitions as to when a customer of an insurance provider can ask for an override in what is known as "step therapy.”  

“Step Therapy” or a “fail-first requirement” is used as a method by insurance companies to control the costs of prescription medications.  

Nikki Perry is the mother of 11-year-old Max Perry, who was born with epilepsy and has suffered from seizures since he was 5 years old. She testified on behalf of the bill during a Banking, Commerce, and Insurance Committee meeting at the Capitol Monday.  

“For the past several years we have struggled to find the right therapy for him,” said Perry. She explained that when neurologists would prescribe a preferred medication for Max, her insurance company would refuse to help pay for it, instead of requiring him to try and fail other medications first. 

As a result, Max had to take several drugs before finding an effective cocktail, all the while undergoing the debilitating side effects of his treatments. 

“Mood instability, nausea, vomiting, diarrhea...self-injury is a big one,” said Perry, "you name it, we had it.” 

Perry believes many of those could have been prevented if she had the option to opt-out of “step therapy,” specifically due to a provision that requires insurers to exempt clients that can prove the provider recommended treatment is ineffective.  

"We need to ensure that people living with these serious and complex healthcare needs, like epilepsy, have meaningful and timely access to most or all of the meds that are necessary to manage their conditions,” said Perry. 

During Monday’s hearing, Executive Director of the Nebraska Insurance Federation, Robert Bell, defended the use of “step therapy” as an effective way to keep costs low, but overall took a neutral position on the legislation. 

Blue Cross Blue Shield of Nebraska, the state’s largest health insurer declined to comment on the bill. 

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