H.R. 5509: Safe Step Act

The Safe Step Act takes aim at a routine insurance practice: before a plan covers the drug your doctor chose, it can require you to try one or more of its preferred alternatives first. Supporters of the bill argue that step therapy delays effective treatment, particularly for people with chronic or complex conditions who already know what works for them.

The bill does not outlaw step therapy. Instead, it requires workplace health plans to build a clear exceptions process and to grant the exception when one of six situations applies: the required drug already failed, it is expected to fail, it is unsafe or contraindicated, it would keep you from functioning at work or in daily life, or you are already stable on the drug your doctor prescribed and another health plan previously covered it.

That last situation matters most to people who change jobs or insurers. If you are stable on a medication and your old plan covered it, your new plan would have to grant the exception rather than restart you on something else.

The bill also tries to make the process workable. Plans would have to use a standard form, accept requests on paper and electronically, ask only for information that is strictly necessary, and let a representative or a third-party advocate file on your behalf. Decisions come with a clock: 72 hours for a standard request, and as little as 24 hours when delay could seriously jeopardize your health, your ability to regain function, or leave you in severe pain. Once granted, an exception lasts at least one year.

The reach is specific. The bill amends federal benefits law that governs private-sector, employer-sponsored group health plans, so it would not change rules for Medicare, Medicaid, or coverage bought on the individual marketplace. Plans would also report exception data to the Labor Department, which would publish an annual analysis for Congress.