Step-therapy reform bill would add bypass, carve out metastatic cancer, advocates say
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Summary
HB 16-38 would create a bypass/appeal pathway for insurer step-therapy (fail-first) protocols and remove step requirements for metastatic cancer patients; patient advocates and medical groups told the committee step therapy can delay or harm care, while carriers and the Insurance Department urged further stakeholder work.
Representative Nagel opened the public hearing on HB 16-38 by saying the bill would create a bypass mechanism for step-therapy when medically necessary and that a work group would be helpful before moving the bill forward.
"What step therapy is for them is more of a rigid thing... it's called a fail first policy," Rep. Nagel explained, adding the aim is not to eliminate step therapy but to ensure clinicians and patients can bypass it when clinical judgment warrants.
Advocates from the rare-disease community and cancer organizations gave emotional testimony about delays and harms. Nancy Bitterman described cases where insurers required trials of other drugs that caused severe reactions and lengthy delays for her daughter: "When the insurance companies tell you this is cost effective, I don't know how it is cost effective when we're having multiple emergency room visits." Angelica Katz of Susan G. Komen urged a specific exemption for metastatic cancer patients, saying their treatment is highly personalized and delays can be life-threatening.
Health-plan representatives, including Sabrina Dunlap of Anthem, opposed the bill as written, arguing it could effectively end step therapy, disrupt clinically appropriate management and that many of the consumer protections the bill targets already exist in statute or rule. Michelle Heaton of the Insurance Department said the department is revising utilization review rules and that many elements (clinical-review criteria, exceptions and expedited processes) are already in current law, but she supported working with stakeholders in an interim study to close any gaps.
Proponents urged interim study and stakeholder negotiation; opponents said targeted rule changes or clearer language might address problems without undermining utilization management. Committee members agreed to further stakeholder work during the interim.
The hearing produced multiple personal testimonies and technical exchanges; no formal vote was recorded.