The state of Texas recognizes the importance of patient protections and leads the way in establishing and improving protections for its citizens through statute.
In 2017, Texan officials worked with key opinion leaders and insurance companies to pass a new law to provide patient protections around the use of step therapy (fail first) protocols. Texas legislators and collaborators hope that this law will maximize access to care and decrease long-term costs for patients.
The purpose of this page is to provide answers to frequently asked questions about this new law and the protections it establishes for patients.
Frequently asked questions:
Step therapy protocols, also known as “fail first” protocols, are insurance policies that force patients to try insurer-preferred medication(s) before a provider-prescribed medication will be covered. Although this makes sense in some cases, there are many cases where it would be more cost-effective and beneficial for the patient if they receive the initially prescribed drug as soon as possible.
The new law is reflected in Chapter 1369 of the Texas insurance code. This new law protects patients from being harmed by these step therapy practices by ensuring that these step therapy policies are informed by non-biased clinical guidelines. It also outlines clear exceptions to step therapy policies and provides a transparent and expedited pathway through which to receive an exception from step therapy requirements.
The new law applies to commercial health insurance plans, like individual or family plans acquired through the insurance marketplace or directly from an insurance company. It does not apply to Medicare (federal) plans, Medicaid fee for service plans, labor benefit plans, or to self-insured employer plans (ERISA plans). Applicable insurance plans will be denoted by “TDI” or “DOI” printed on the insurance card.
The new law:
TDI’s informal rule proposals, proposed and adopted rules are posted here: http://www.tdi.texas.gov/rules/index.html.
The utilization review (appeal) process in the law states that a health insurer (utilization review agent) shall grant a step therapy protocol override upon receipt of information that includes supporting rationale and documentation from a health care provider which demonstrates that the drug(s) being required by the health insurer:*
If your care provider can show proof that step therapy will harm you, an insurer must approve your request to bypass step therapy protocols.
*The standards included in the new law for the process listed above do not prevent a health insurer from requiring a patient to try an AB-rated generic equivalent drug before authorizing coverage for the equivalent brand-name prescription drug being ordered by a prescriber.
If the insurer fails to respond within the required time frames, the appeal (override) of the required step therapy protocol will be granted in favor of the patient.
If a patient (or a healthcare provider on his/her behalf) receives a denial to a step therapy protocol override request, he/she has the right to appeal the determination under Subchapters H and I, Chapter 4201 of the Insurance Code.
The new law will take effect on September 1, 2018. It applies to health insurance plans delivered, issued for delivery, or renewed after that date.
Under the new law, the Insurance Commissioner of Texas is authorized to promulgate any rules or regulations necessary for the timely implementation of the law.
To learn more, or file complaints, visit the Texas Department of Insurance Consumer Protections department website (see below link).
Be sure to carefully read directions for how to submit a complaint and submit any relevant documentation along with your complaint (e.g., adverse determination letter, forms for independent review requests, etc.)
For Texans with disabilities: http://www.tdi.texas.gov/pubs/consumer/cb039.html
For managed care plans: http://www.tdi.texas.gov/pubs/consumer/cb069.html
To Stay Connected to TDI, sign up at: https://public.govdelivery.com/accounts/TXINSUR/subscriber/new?qsp=CODE_RED
For information about health insurance in Texas in general: http://www.texashealthoptions.com/index.html