Advocacy in New York

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State Fact Sheet 
Find out how arthritis affects people in New York and what you can do to make a difference. 

State of Your Health 
If you are experiencing a barrier to care, you should contact your insurance commissioner, who can help address your situation. Please be sure to view our New York Department of Insurance fact sheet that gives instructions on how to appeal, request an external review or file a complaint with your insurance commissioner.

What is  step therapy?   

Step therapy is a practice used by insurers that requires people with arthritis to try lower-cost medications before permitting more expensive treatments, even when the doctor wants to prescribe them. In other words, more expensive and effective drugs can only be prescribed if the cheaper ones prove ineffective.  

How does this new law address step therapy in  New York?  

In 2016, New York passed legislation to address step therapy and the law went into effect in early 2018.  This new law increases the ability of the patient’s health care provider, not insurance company, to make important decisions about a patient’s treatment.  The law includes two basic patient protections that will improve the safety and efficacy of step therapy protocols.  First, it requires that clinical review criteria, used by an insurer to establish fail first protocols, is based on science and evidence-based clinical practice guidelines and not exclusively driven by cost.  Second, the bill requires a clear and expedient process (timelines of 72 hours or 24 for an emergency) that can be used by physicians and other prescribers to request an override of a fail first protocol.  There will be immediate coverage for a prescription drug if decision that step therapy should be overridden.   

Which patients will benefit from this new law?  

The new law applies to state-regulated commercial health insurance plans, HMO plans, Medicaid Managed Care plans and Child Health Plus plans.  The new law does not apply to Medicare, Medicaid fee for service or “self-insured” plans, which are exempted by the federal Employee Retirement Income Security Act of 1974 (ERISA).  To learn if you are covered, contact your insurer and provide your policy number.    

What should I do if I experience this barrier to care in  New York?  

If you are experiencing a barrier to care, you should contact your insurance commissioner, who can help address your situation. You can easily find instructions on how to appeal, request an external review, or file a complaint to your Insurance Commissioner with our Department of Insurance one pager, click here to learn more. 

• Learn more about how the law affects New York by watching this short video!
• View or download the video slides
• View and print our easy to use handout explaining the impact of the new law

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