May 5, 2020
Access Issues, Insurance, Patients, Providers
From the Broomstick of Julie Baak Pharmacy Benefit Managers (PBM) are the middlemen that do none of the work and make most of the money. Fun Fact: PBMs have their MBAs tell […]
April 29, 2020
Infusion Patients, Insurance, Patients
Written by Marissa Shackleton, The Elliot Lewis Center, Wellesley, MA As the Executive Director of a multiple sclerosis center, I believe medications should be accessible and […]
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When you login, you will be directed to admin.infusioncenter.org. When you get there:
You will receive an email with a link to click that will log you into the resources section of the locator, which includes your claimed and/or activated infusion center(s).
Please note: you will have to enter your email each time as we no longer have passwords for extra security. This login process is separate from the forum.
If you have questions about the email address associated with the location, how to add or claim a center, how to purchase a resource, etc., please email our Member Relations lead, Ashley Kana at [email protected].
Great news – Kentucky has step therapy protections.
This law (§304.17A-163) requires insurers to grant an exception if a health care provider demonstrates any of the following:
– the drug an insurer wants a patient to take is likely to cause an adverse reaction;
– the drug an insurer wants a patient to take is expected to be ineffective;
– a patient has tried and failed the drug before;
– the drug is not in their best interest; or
– a patient is stable on their current medication while on their current or previous health plan.
A health care provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 48 hours indicating whether the step therapy exception request has been approved, denied, or they require more information. If they do not provide a response within the timeline, the exception request shall be deemed approved.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §304.17A-163, you can file a complaint with Kentucky’s Department of Insurance.
File a complaint with DOI Read the full statute hereGreat news – Kansas has step therapy protections, but only for Medicaid.
This law (39-7,121) requires insurers to grant an exception if a health care provider demonstrates any of the following:
– the drug an insurer wants a patient to take is likely to cause an adverse reaction;
– the drug an insurer wants a patient to take is expected to be ineffective;
– a patient has tried and failed the drug before; or
– a patient is stable on their current medication.
A health care provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 72 hours that the step therapy exception has been approved, denied, or they require more information.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with 39-7,121, you can file a complaint with Kansas’s Department of Insurance.
Great news – Iowa has step therapy protections.
This law (§514F.7 Iowa Code) requires insurers to grant an exception if a health care provider demonstrates any of the following:
– the drug an insurer wants a patient to take is likely to cause an adverse reaction;
– the drug an insurer wants a patient to take is expected to be ineffective;
– a patient has tried and failed the drug before; or
– a patient is stable on their current medication while on their current or previous health plan.
A health care provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within five calendar days indicating whether the step therapy exception request has been approved, denied, or they require more information.
In emergency cases, the insurer must respond within 72 hours.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §514F.7 Iowa Code, you can file a complaint with Iowa’s Department of Insurance.
File a complaint with DOI
Read the full statute here
Great news – Indiana has step therapy protections.
This law (IC 27-8-5-30, IC 27-13-7-23, or IC 5-10-8-17) requires insurers to grant an exception if a health care provider demonstrates any of the following:
– the drug an insurer wants a patient to take is likely to cause an adverse reaction;
– the drug is expected to be ineffective;
– The patient has already received the same or similar drug as part of a step therapy protocol;
– a patient has tried and failed the drug before; or
– the drug is not in their best interest.
A health care provider can request an exception on behalf of a patient, if they match any of the above criteria.
An insurer must respond within 3 business days letting a patient know whether their step therapy exception request has been approved, denied, or they require more information.
In emergency cases, the insurer must respond within 1 business day.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with IC 27-8-5-30, IC 27-13-7-23, or IC 5-10-8-17, you can file a complaint with Indiana’s Department of Insurance.
File a complaint with DOI Read the full statute here
Great news – Illinois has step therapy protections.
These law (§215 ILCS 134/45.1 and 215 ILCS 5/356z.80) require insurers to grant an exception if a health care provider demonstrates any of the following:
– the drug an insurer wants a patient to take is likely to cause an adverse reaction;
– a patient has tried and failed the drug before; or
– a patient is stable on their current medication while on their current or previous health plan.
A health care provider can request an exception on behalf of a patient, if they match any of the above criteria.
An insurer must respond within 72 hours letting a patient know whether their step therapy exception request has been approved, denied, or they require more information.
In emergency cases, the insurer must respond within 24 hours.
State-regulated commercial and managed care plans are also specifically prohibited from imposing step therapy requirements on treatments for Alzheimer’s.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §215 ILCS 134/45.1 and/or 215 ILCS 5/356z.80, you can file a complaint with Illinois’s Department of Insurance.
File a complaint with DOI
Read the full statute of §215 ILCS 134/45.1 here
Read the full statute of 215 ILCS 5/356z.80 here
The state of Hawaii has yet to pass step therapy reform. Contact your state legislators and ask for their support.
Contact your legislatorsIf a patient has been subjected to step therapy, a health care provider can request an exception.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
Great news – Georgia has step therapy protections.
This law (O.C.G.A. § 33-24-59.25) requires insurers to grant an exception if a health care provider demonstrates any of the following:
– the drug the insurer wants the patient to take is likely to cause an adverse reaction;
– the drug the insurer wants the patient to take is expected to be ineffective;
– the patient has tried and failed the drug before; or
– the patient is currently stable on a drug while on their current or an immediately previous health plan;
A health care provider can request an exception on behalf of a patient, if they match any of the above criteria.
An insurer must respond within two business days notifying a patient that the exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with O.C.G.A. § 33-24-59.25, you can file a complaint with Georgia’s Department of Insurance.
Great news – Florida has step therapy protections.
This law (Title XXXVII, ss. 627.42393) requires insurers to grant a step therapy exception if a health care provider demonstrates that a patient has previously completed a step therapy protocol with another health plan, and the plan paid for the requested drug during the 90 days preceding this request.
If an insurer does deny an exception request, a health care provider has the right to file an appeal on behalf of a patient. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with ss. 627.42393, you can file a complaint with Florida’s Department of Insurance.
Great news – Connecticut has step therapy protections.
This law (Chapter 700C, Sections 38A-510 and 38A-544) requires insurers to grant an exception if a health care provider demonstrates any of the following:
A health care provider can request an exception on behalf of a patient, if they match any of the above criteria.
Starting January 1, 2026, insurers are prohibited from requiring step therapy for longer than 30 days for drugs treating multiple sclerosis or rheumatoid arthritis. After this period, the provider may deem that treatment ineffective and authorize dispensation of and coverage for the drug originally prescribed by the provider, provided the drug is covered under the patient’s health plan.
Protections in Connecticut include Medicaid.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with Chapter 700C, Section 38A-510 or Section 38A-544, you can file a complaint with Connecticut’s Department of Insurance.
Great news – Colorado has step therapy protections.
This law (Colo. Rev. Stat. § 10-16-145) requires insurers to grant an exception if a health care provider demonstrates any of the following:
A health care provider can request an exception on behalf of a patient, if they match any of the above criteria. The insurer must respond to an exception request within three business days stating whether the request is approved, denied, or they need more information. In emergency cases, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with HB 1370, you can file a complaint with Colorado’s Department of Insurance.
Great news – California has step therapy protections.
This law (§1367.206) requires insurers to grant an exception if a health care provider demonstrates any of the following:
A health care provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §1367.206, you can file a complaint with California’s Department of Insurance.
Great news – Arkansas has step therapy protections.
This law (§23-79-2104) requires an insurer to grant a step therapy exception if a health care provider demonstrates that:
An insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §23-79-2104, you can file a complaint with Arkansas’s Department of Insurance.
Great news – Arizona has step therapy protections.
This law (§20-3654) requires insurers to grant an exception if a health care provider demonstrates any of the following:
A health care provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §20-3654, you can file a complaint with Arizona’s Department of Insurance.
Great news – Arizona has step therapy protections.
This law (§20-3654) requires insurers to grant an exception if a health care provider demonstrates any of the following:
A health care provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond to the exception request within 72 hours granting the exception, denying the exception, or asking for additional information. In cases of emergency, the insurer must respond within 24 hours. If the insurer does not respond within the prescribed timeframe with a denial or request for more information, the exception shall be deemed granted.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with §20-3654, you can file a complaint with Arizona’s Department of Insurance.
The state of Alabama has yet to pass step therapy reform. Contact your state legislators and ask for their support.
If a patient has been subjected to step therapy, a health care provider can request an exception.
If a patient’s exception has been denied, a health care provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request.
