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Bill Standardizes Appeals Process for Prescription Drug Coverage Denial

Jenifer Jones

A bill standardizing the appeals process for prescription drug coverage is heading to its final hurdle before the governor’s desk.

Senate Bill 155 focuses on step therapy programs and gives patients an appeal option if a new carrier denies coverage of a previously approved drug.

A step therapy program tracks a patient’s reaction to a sequence of drugs in order to find the most effective treatment. It’s often used for rheumatoid arthritis, diabetes, depression and many other conditions.

But if a patient changes insurance providers, they may be denied coverage until they go through the process again. Representative Michael Diedrich says that’s a problem.

“We don’t want a step back therapy," he says, "We want a step therapy program you can appeal to the new carrier and say, I have the medical documentation, I have the experience, this is my patient profile, this is my reaction, this is the level I’m at. I want an exception from having to start over in the drug program.”

The bill requires a decision within five days of the appeal, or 72 hours in an emergency.

The only opposing testimony came from Randy Moses of the Independent Insurance Agents of South Dakota.

“I’m not gonna argue it’s gonna be a huge premium impact. I don’t have an actuarial study. I can’t tell you what the number would be. But at some point in time I think we need to take stock of where we’re at," he says. "We’ve continually put mandates on the books, and we’re talking about another one here.”

But members of the Health and Human Services Committee agree this bill standardizes a necessary process. Committee Chair Kevin Jensen has firsthand experience.

“This has happened to me twice in my life, and both times it took me quite a while to get restabilized. It was Type 2 diabetes, and each time the plan changed it really did affect me"

The bill passes out of the House Health and Human Services Committee unanimously.