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March 13, 2019

Gov Northam Signs Step Therapy Regulations into Law

Richmond, VA – Virginia Governor Ralph Northam today signed legislation regulating the use of step therapy by insurers, an anticipated move that still prompted praise and excitement by patients, providers and advocates alike throughout the Commonwealth.


The new law reforms step therapy, or “fail first” protocols, in which patients must try an inexpensive treatment before insurers will cover a more expensive one, even when providers are confident that the inexpensive treatment will not work. The law improves step therapy protocols by creating an expedited, transparent and evidence-based system when a patient’s unique situation requires a deviation from step therapy.


While the bill will not require an insurer to cover a medication that is not otherwise included in its benefit design, the bill ensures that patients have the chance to have access to a prescribed medication when they have either documented medical necessity or have already tried an insurer’s preferred drug – even if it was during a time they were part of a different health plan.


The bill also mandates that insurers must make a decision within 72 hours – including weekends, holidays and after business hours. In emergencies, insurers must notify patients of a decision within 24 hours.


“We’ve seen the direct impact that bad step therapy protocols can have on the lives of patients and their families. We’ve worked with patients who have had to restart on treatment protocols that haven’t worked for them each time they switched insurers, pushing back their recovery and resulting in job losses, health deterioration and financial ruin. While we understand—and support—reasonable step therapy protocols to keep systemic costs low, there must always be humanity in the protocols so that patients are not denied the treatment that has the best possible chance at curing them,” said NPAF CEO Alan Balch, PhD. “This legislation is great news for people throughout Virginia.”



NPAF worked with Fair Health VA, a coalition of patient, provider, and health care groups committed to securing access to life-saving treatments for Virginians, particularly those with chronic conditions. NPAF volunteers, along with patients from sister organization Patient Advocate Foundation headquartered in Hampton, championed this issue in Richmond and within their home offices, sharing their stories as examples of the negative effects that step therapy protocols can have when improperly utilized.


Virginia now joins 19 other states that have reformed step therapy regulations.