A new law aimed at helping Wisconsin patients access important prescription medications will go into effect on Nov. 1, 2019.

Called the Step Therapy Law, Wisconsin Act 12 establishes a new set of requirements that health insurance companies have to follow when requiring a patient to try a different and less expensive treatment option than the one prescribed by the patient’s doctor. Gov. Tony Evers signed the Step Therapy bill into law in July 2019.

“When a patient is prescribed a specific prescription drug by their doctor, they should be confident that they will be able to access that medication or similar one that meets their health care needs,” said Insurance Commissioner Mark Afable, a Sun Prairie resident.

“The new Step Therapy Law will help patients access the medications they need while allowing insurers to still take steps to control costs," Afable added. "So many patients, doctors, advocates, and insurers worked together on this new law. We believe it will have a positive impact on the lives of folks throughout Wisconsin.” 

The Step Therapy Law requires that all insurers or their contracted pharmacy benefit managers or utilization review organizations that have a step therapy protocol for prescription medications must meet certain requirements, including:

• The protocol must be based upon clinical review criteria;

• The process and criteria for selecting and evaluating clinical practice guidelines used to develop the protocol must be posted to the entity’s website;

• The process to request an exception must be clear, accessible, and convenient; and,

• An appeal process must be established for insureds whose request for an exception is denied.

While the Step Therapy Law goes into effect on November 1, plans using a step therapy protocol have until January 1, 2020, to ensure that they comply.

The Office of the Commissioner of Insurance (OCI) issued a bulletin to insurers and interested parties on Oct. 16 summarizing the new law.

A formal rule-making process will commence shortly after the law takes effect during which time patients, doctors, advocates, and insurers will have additional opportunities to have input on the applicable rules.

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