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Full Report for Full Citations and References California Health Benefits Review Program Analysis of California Assembly Bill 2144 Step Therapy A Report to the 2019–2020 California State Legislature April 14, 2020 Key Findings Analysis of California Assembly Bill 2144 Step Therapy Summary to the 2019–2020 California State Legislature, April 14, 2020 CONTEXT1 AT A GLANCE For commercial/CalPERS enrollees, the version of A pharmacy benefit covers outpatient mediations and California Assembly Bill 2144 analyzed by generally involves a formulary, which generally indicates CHBRP would specify conditions for step therapy which drugs are preferred. Use of preferred drugs results and prior authorization protocols when applied to in less cost sharing for the enrollee. a pharmacy benefit. AB 2144 exempts the health insurance of Medi-Cal beneficiaries enrolled in Step therapy or “fail-first” is a utilization management plans regulated by the Department of Managed protocol that can be applied to one or more medications. Health Care (DMHC). Its purposes are to control costs, manage safety and medication compatibility, and enforce clinical guidelines 1. CHBRP estimates that of the 21.7 million and compliance with Food and Drug Administration Californians enrolled in state-regulated health (FDA) indications for use. It can require an enrollee to try insurance, 13.4 million of them will have and fail one or more medications prior to receiving insurance subject to AB 2144. coverage for the initially prescribed medication. Step 2. Benefit coverage. Commercial/CalPERS therapy protocols usually require starting with a less enrollees have near compliant benefit coverage, expensive (generic) mediation and may require starting but for 1.1 million, AB 2144 would require step with a less potent medication or dosage (graduating to therapy exemptions for some new enrollees. more potent medications as necessary). Step therapy override requests follow a procedure by which a 3. Utilization. No change for prior authorizations, but prescriber documents to the plan/insurer why an enrollee 544 more step therapy overrides (a 0.87% should be allowed to skip one or more of a step therapy increase) would to be approved for protocol’s steps. commercial/CalPERS enrollees. 4. Expenditures. Total net annual expenditures Prior authorization — also known as precertification, would increase by $721,000, or less than 0.01%, prior approval, or prospective review — is another for commercial/CalPERS enrollees. utilization management protocol that can be applied to one or more medications. Its purposes are to control 5. Medical effectiveness. There is insufficient costs, ensure medication compatibility, enforce clinical evidence to determine whether step therapy or guidelines and compliance with FDA indications for use, prior authorization protocols directly affect health and protect patient health outcomes. Prior authorization outcomes, although there is a preponderance of also supports the formulary, as coverage for non- evidence that step therapy reduces use of any formulary medications generally requires prior medication for a condition. A decrease in authorization. Under prior authorization, providers must medication use may be harmful if medication is document the medical necessity of a prescription and essential for effective treatment of the condition. obtain the plan/insurer’s approval before a pharmacy 6. Public health. No public health impact is can fill the prescription. expected regarding prior authorization, as commercial/CalPERS enrollee benefit coverage Similar to other utilization management protocols, step is already compliant. The public health impact of therapy and prior authorization protocols, when applied the more step therapy overrides is unknown due to a pharmacy benefit, vary between plans and policies. to insufficient evidence regarding the direct impact of such protocols on health outcomes. BILL SUMMARY Please note that the absence of evidence is not evidence of no effect. AB 2144 would address application of step therapy and prior authorization protocols to the coverage of outpatient prescription medications. 1 Refer to CHBRP’s full report for full citations and references. Current as of April 14, 2020 www.chbrp.org i Key Findings: Analysis of California Assembly Bill 1986 Regarding step therapy, AB 2144 would: Figure A. Health Insurance in CA and AB 2144 • Prohibit requiring new enrollees to repeat step therapy; • Require use of a clinical peer (who was not Medi-Cal (DMHC involved in the initial decision) to review appeals; Regulated), 8,356,000 Uninsured, 3,547,000 • Allow an enrollee’s designee, guardian, primary care physician, or health care provider to file an Insured, Not Subject to Mandate*, 11,953,000 appeal of a denial of prior authorization or step CDI and DMHC Regulated (Not Medi- therapy exception request; and Cal), 13,363,000 Medi-Cal FFS, 977,000 • Require granting exemption requests if: Medi-Cal COHS, 1,607,000 o The required medication is contraindicated Source: California Health Benefits Review Program, 2020. or may cause an adverse reaction or Notes: * Medicare beneficiaries, enrollees in self-insured products, etc. physical/mental harm; o The required medication is expected to be ineffective (based on known characteristics IMPACTS of the enrollee and/or the medication); o The enrollee has tried: (1) the required Benefit Coverage, Utilization, and Cost medication, (2) another medication in the same class, or (3) another medication with Approximately 91.7% of commercial/CalPERS enrollees the same mechanism and discontinued due in plans and policies regulated by DMHC and CDI have to lack of effectiveness, diminished effect, or benefit coverage that is fully compliant with AB 2144’s adverse event; requirements. The remaining enrollees have benefit coverage compliant with AB 2144’s other aspects, but o The required medication is not in the best require some new enrollees to repeat step therapy interest of the enrollee, based on medical (which AB 2144 would prohibit). Postmandate, all necessity; or commercial/CalPERS enrollees would have benefit coverage that is fully compliant with AB 2144. o The enrollee is stable on a medication covered by their current or previous Utilization plan/policy. No change in the 1,493,526 prior authorizations for Regarding step therapy and prior authorization, AB 2144 commercial/CalPERS enrollees would be expected for would: 2021, as related benefit coverage is already compliant with AB 2144. However, postmandate, CHBRP would • require approval/denial responses to exemption expect the 544 more step therapy overrides (a 0.87% requests within 72 hours if nonurgent and within increase) to be granted to people who are newly enrolled 24 hours if urgent. Nonresponse would be in a commercial/CalPERS plan/policy in 2021 and ask to deemed an approval for the exemption request. be exempt from repeating step therapy. AB 2144 exempts the health insurance of Medi-Cal Expenditures beneficiaries enrolled in plans regulated by the Department of Managed Health Care (DMHC) from As noted in Figure B, AB 2144 would increase total net these requirements. annual expenditures by $721,000, or less than 0.01%, for commercial/CalPERS enrollees. Current as of April 14, 2020 www.chbrp.org ii Key Findings: Analysis of California Assembly Bill 1986 Figure B. Expenditure Impacts of AB 2144 • Preponderance of evidence suggests that step therapy protocols reduce rates of initiation, continuation, and adherence to any prescription Employer Premiums $456,000 medication used to treat a disease or condition. Reduction in initiation, continuation, or Individual Premiums $3,000 adherence to any prescription medication for a disease or condition may be harmful if the Employee Premiums $137,000 medication is essential for effective treatment of the condition. Medi-Cal Managed Care Plan $0 Expenditures • There is insufficient evidence to determine Enrollee Out-of-Pocket Expenses whether step therapy protocols affect the $125,000 for Covered Benefits effectiveness of treatment for diseases or Enrollee Expenses for conditions. The absence of evidence is not Noncovered Benefits $0 evidence of no effect. It is an indication that the Source: California Health Benefits Review Program, 2020. impact of step therapy protocols on treatment effectiveness in unknown. Medi-Cal • There is insufficient evidence to determine whether step therapy protocols directly affect As AB 2144 exempts the benefit coverage of Medi-Cal beneficiaries enrolled in DMHC-regulated plans from health outcomes. The absence of evidence is compliance, AB 2144 would have no impact on Medi- not evidence of no effect. It is an indication that Cal. the impact of step therapy protocols on health outcomes in unknown. CalPERS For prior authorization: AB 2144 is expected to have no impact on CalPERS • There is limited evidence that prior authorization enrollees, because all have benefit coverage compliant with AB 2144 at baseline. protocols reduce use of medications subject to these policies. Whether reduction in use benefits Number of Uninsured in California or harms consumers depends on the medication and the availability of other equally effective As impacts on expenditures are less than 1%, no medications with similar side effects. measureable impact on the number of uninsured Californians is projected. • There is limited evidence that prior authorization protocols increase use of other prescription medications. Whether increase in use of other Medical Effectiveness medications benefits or harms consumers depends on the medication.
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