Step Therapy Legislation by State

Do these protections apply to my insurance plan?

We recommend that anyone with a commercial plan, including an employer plan, use the step therapy exception request forms provided in the map above if they need to seek a step therapy exception.

Generally, these state laws apply to the following plans:

• Individual and small group plans (i.e. Exchange plans)
• Fully-insured employer plans

In addition, the state information in the map above will indicate if the step therapy protections apply to the state’s Medicaid program. While only a few states have implemented step therapy guardrails on their Medicaid programs through legislation, many more have put patient protections in place through agency-level regulation. Please reach out to your state’s Medicaid program for more information about step therapy in your state if you still have questions after consulting our map.

Employer plans are regulated by the federal Department of Labor, and self-insured employer plans are outside the scope of these state laws. As few consumers, plan administrators, or HR staff know if their plan is fully- or self-insured, we recommend using the exception request form for your state, which cites the state law.

Help us bolster patient protections for the approximately 100 million individuals with self-insured employer plans by joining us in advocating for federal step therapy reform, the Safe Step Act.

What is the solution?

The NPF policy team has worked in collaboration with other patient and provider groups to craft model legislation that impacts all people with a chronic disease – all of whom are negatively affected by step therapy. The NPF supports the passage of that model legislation, which ensures step therapy is based on the most current clinical data and that it is available to the consumer in a transparent manner. Furthermore, it provides a timeline for responses to requests that is based on language agreed upon in other states. Finally, it outlines clear and concise exceptions to the step therapy protocols based on medical necessity. This legislation, which is not a ban and does not lead to additional costs, strikes a fair balance between cost containment and the health of the patient.

U.S. Congress is taking action as well!

Our success at the state level has led to a Federal effort focused on amending the Employee Retirement Income Security Act (ERISA) to require a group health plan to provide a step therapy exception process. Authored by Representatives Raul Ruiz and Brad Wenstrup, the Safe Step Act was first introduced in 2017 with a Senate companion bill in 2019.

Ask your member of Congress to support the Safe Step Act by sending them a message.

Read the flyer on the Safe Step Act.