November 6, 2023
Commissioner Mike Causey
North Carolina Department of Insurance
325 N Salisbury Street
Raleigh, North Carolina 27603
Re: Health Insurers Blocking Access to Health Care for North Carolina Patients
Dear Commissioner Causey:
Fair Health North Carolina (FHNC) is a coalition of North Carolina’s leading patient and provider organizations committed to ensuring North Carolinians can access and afford the medications they need. We write to thank you for your leadership in confronting North Carolina’s health care access and affordability challenges and urge you to take additional action to ensure patients don’t continue to face burdensome health insurance protocols that block access to care.
Many North Carolina patients, particularly those living with chronic conditions, require consistent and reliable access to the treatments they need to manage symptoms and control their illness. However, in the name of cost containment, health insurers have increasingly adopted protocols that restrict patient access, create unnecessary administrative hurdles for health care providers, and improve insurers’ bottom lines at the expense of vulnerable patients. Under a policy known as step therapy, patients are required by their insurance company to try and fail on one or more medications, typically an older or lower cost medicine, to treat a condition before they can “step up” to their prescribed treatment.
According to North Carolina statute §58-3-221, patients and providers must have access to a step therapy exemption process that is easily accessible on an insurer’s website. It also says certain health plans must grant an exception request if a provider can demonstrate:
The patient has tried the prescriber-requested drug while covered by a current or previous health plan;
The insurer-required drug has been ineffective in treatment of the patient’s condition;
The insurer-required drug causes or is expected to cause adverse clinical reactions; or
The patient has previously tried the insurer-required drug or device, and it has been detrimental to the patient’s health or has been ineffective in treating the condition and is likely to be detrimental or ineffective again.
Despite this statute, patients continue to be burdened by the onerous step therapy protocols the law is intended to alleviate. When a patient can’t access their prescribed treatment plan, they may be forced to skip or abandon medications, leading to even higher medical costs down the road, such as extra doctor appointments, hospitalizations, and emergency room visits, as well as long-term health impacts.
It is critical that the North Carolina Department of Insurance issue guidance on §58-3-221 to ensure North Carolina health insurers are complying by the law in order to improve patient access to critical health care. Many other State Insurance Commissioners with similar bills have issued bulletins to provide guidance, including Oklahoma, Maryland, and Wisconsin. Patients across North Carolina are counting on you to protect them from unnecessary barriers to care – we are reaching out to you today to request that you issue a similar bulletin regarding this important law.
Charlene Cowell, MPA
Executive Director, Bleeding Disorders Foundation of North Carolina
Chair, Fair Health North Carolina