Ama Policy

Step Therapy D-320.981

Step Therapy Override

1. Our AMA believes that step therapy programs create barriers to patient care and encourage health plans to instead focus utilization management protocol on review of statistical outliers.

2. Our AMA will advocate that health plan step therapy protocols, if not repealed, should feature the following patient protections:

a. Enable the treating physician, rather than another entity such as the insurance company, to determine if a patient “fails” a treatment;

b. Exempt patients from the step therapy protocol when the physician believes the required step therapy treatments would be ineffective, harmful, or otherwise against the patients’ best interests;

c. Permit a physician to override the step therapy process when patients are stable on a prescribed medication;

d. Permit a physician to override the step therapy if the physician expects the treatment to be ineffective based on the known relevant medical characteristics of the patient and the known characteristics of the drug regimen; if patient comorbidities will cause, or will likely cause, an adverse reaction or physical harm to the patient; or is not in the best interest of the patient, based on medical necessity;

e. Include an exemption from step therapy for emergency care;

f. Require health insurance plans to process step therapy approval and override request processes electronically;

g. Not require a person changing health insurance plans to repeat step therapy that was completed under a prior plan; and

h. Consider a patient with recurrence of the same systematic disease or condition to be considered an established patient and therefore not subject to duplicative step therapy policies for that disease or condition.

Policy Timeline

Res. 714, A-19 Modified: Res. 815, I-19 Reaffirmation: A-22