Step Therapy Eliminated in California During COVID-19

Gov. Gavin Newsom issued an executive order temporarily eliminating step therapy for Medi-CAL recipients. This executive order was implemented during the onset of the COVID-19 pandemic to remove barriers to needed prescription drugs for Californians.

What is step therapy?

Step therapy, also known as “fail first” or “utilization management”, is a process used by health insurers which requires patients to try one or more medications specified by the insurance company first before paying for the medication their physician would prefer to start them on. Typically, the medications specified that must be tried first are generic or lower cost medicines. Patients must then “fail” on that specified medication(s) before the insurance company will approve or cover a “step up” to another medicine that may be more expensive for the insurer, but likely a better fit or a more effective medication for the patient’s condition.

Why is this significant?

This is significant for all breast cancer patients, but especially important for our metastatic (MBC, stage IV or breast cancer that has spread) breast cancer community.

While MBC can be treated, there is no cure and MBC patients are faced with the reality that they will be on and off anti-cancer medications for the rest of their lives. Ensuring MBC patients have the treatment originally prescribed to them can be a matter of life or death, as their disease is likely to get worse while on the health plan-preferred drug.

Under Gov. Newsom’s executive order, breast cancer patients in California can now have their insurance companies pay for the medication(s) their physicians recommend without having to “fail first” on other medications, for the near future.

Will this change be permanent?

Susan G. Komen is urging this change to be permanent. The Komen California affiliates sponsored bill AB 2144 by Assemblymember Arambula which helps eliminate step therapy by ensuring physicians make the decision of treatment rather than the health plan on a state level. Susan G. Komen is also supporting federal bills HR 2279 and S. 2546 to reform step therapy on a national level.

Susan G. Komen will never stop fighting for the over 155,000 men and women currently living with MBC in the United States. Since its inception in 1982, Susan G. Komen has invested over $210 million in MBC research and next to the U.S. government, Susan G. Komen is the largest nonprofit funder of breast cancer research in the world.

To learn more about step therapy and breast cancer, click here.