Prohibits the application of fail-first or step therapy protocols to coverage for the diagnosis and treatment of serious mental health conditions

• Democratic11
• Republican1

◆ The sponsor's argument

Why Patricia Fahy says this is needed

"Fail-first" or "step therapy" protocols imposed by insurers obligate patients to try a less costly and potentially less effective treatment than what might be prescribed and preferred by their provider, and "fail first" with that before the insurer will cover the more costly treat- ment. This often requires patients to take medications that they have tried previously without success, to wait months for approval to switch to another medication after failing with a given drug, or to suffer adverse effects from a drug they did not want to take. Published studies on the impact of step therapy policies have found that, contrary to their intent, such policies can increase total utili- zation costs over the long run because of increased inpatient admissions and emergency department visits and increasing the time it takes for these patients to "stabilize" on the medications that actually work to treat their condition. Similarly, prior authorization requirements add lengthy delays for patients to access treatment, especially for prescription drugs. These types of policies and restrictions are espe- cially dangerous when dealing with treatment of serious mental health conditions. People suffering from these dangerous conditions often are at severe risk of deterioration, self-harm and harm to others if they cannot access their needed medication in a timely, consistent manner. While New York State's insurance laws already require the treatment of mental health conditions to not apply treatment limitations that are more restrictive as all other medical and surgical benefits, this does not prohibit the use of such limitations on serious conditions. Treatment limitations such as step therapy, fail-first protocols and prior authorization requirements for prescription drugs that treat seri- ous mental health conditions is not in the therapeutic best interest of patients. Sometimes it takes weeks or months to find the "right" medica- tion or dosage to stabilize a patient. Subjecting patients to these treatment limitations can postpone recovery, and even increase the like- lihood of morbidity of patients.

This is the sponsor's own case for the bill, quoted from their memorandum. It is not Agora's description of what the bill does.