Wisconsin is the latest Midwest state to regulate ‘step therapy’

August 15, 2019

Insurance companies may no longer dictate which medications patients in Wisconsin are allowed under protocols known as “step therapy” (or “fail first”).

Wisconsin becomes the sixth Midwestern state — joining Illinois, Indiana, Minnesota, North Dakota and Ohio — to regulate step therapy, which typically requires patients to begin treatment with the most cost-effective drug therapy, progressing to more expensive or risky treatments only if necessary.

SB 26, signed by Gov. Tony Evers in July, requires exceptions to step therapy regimens under limited circumstances, including when a drug is contraindicated (deemed medically inadvisable) for a patient or will cause an adverse reaction; if it’s expected to be ineffective; if it is ineffective or has been previously tried with adverse results; if the drug is not in the patient’s best interest or if the patient is already stable on a different drug under his or her current or past plan.

The new law also mandates that if a patient appeals a denial of a step therapy protocol exception, the insurance company must grant or deny that request within 72 hours (or 24 hours under emergency circumstances); any request for exception not answered by that deadline is considered granted.