Advocacy in West Virginia

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State Fact Sheet 
Find out how arthritis affects people in West Virginia 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 West Virginia Office of the Insurance Commissioner 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  West Virginia?  

In 2017, West Virginia 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 establishes a clear channel for patients and practitioners to request an override when an insurance provider levies such mandate.  The override process must be easily accessible on the health plan insurer’s website.    

Medical exceptions include:    

• required prescription is contraindicated  

• required prescription is expected to be ineffective based on patient   

• patient has tried and failed the prescription  

• prescription is not in best interest of patient  

• patient is stable on prescription   

Which patients will benefit from this new law?  

The new law will apply to patients who receive benefits from entities required to be licensed under this chapter that contracts, or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefit plan, including accident and sickness insurers, nonprofit hospital service corporations, medical service corporations and dental service organizations, prepaid limited health service organizations, health maintenance organizations, preferred provider organizations, provider sponsored network, and any pharmacy benefit manager that administers a fully-funded or self-funded plan.  To learn if you are covered, contact your insurer and provide your policy number.   

• Learn more about how the law affects West Virginia 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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