Julie Kohler of Arizona has been taking meds for her neuropathy for 12 to 15 years now. Neuropathy is a painful, PAINful condition that affects millions in their hands and feet. The 19 drugs Julie takes allow her to function each day without that excruciating pain.
One drug she takes for pain is Cymbalta, an expensive drug that is prescribed for a number of problems, including diabetic neuropathy and fibromyalgia, both very painful conditions. It is part of a class of drugs called SSNRIs, which are mostly known for treating depression. Julie has taken it for years.
So you can imagine how surprised she was when she went to pick up her prescription at the pharmacy, only to be told it was no longer covered, and she would have to pay more than $300 if she wanted it! When she contacted her payer, HealthChoice, she was told they would no longer cover the cost of the drug until she underwent "step therapy."
Step therapy is an approach to prescribing drugs that insists that the least expensive drug in any given class be given to the patient first. If it's effective then -- good! If not, then the next least expensive drug will be tried... and so forth. Step therapy, also called step protocol, is used by health insurers to control costs.
That's fair. Controlling costs is good for all of us, and if a less expensive drug works, then that's a good thing.
But in Julie's case, the imposition by her payer was a bad move. She had previously tried the earlier-step drugs and they had not worked. So all of a sudden she found herself having to defend her doctor's prescription for the Cymbalta.
What's wrong here is that HealthChoice imposed the step therapy after Julie was already successfully taking the Cymbalta and after she had unsuccessfully tried the other, less expensive drugs. That's clearly a violation of their commitment to their insured patient.
Fortunately Julie had kept good records -- she was able to prove to HealthChoice that she had taken the drugs that would not work.
And that's my advice to you today. If you take any sort of branded drug, keep good records of those drugs and their effects, pro and con.
Did you take a drug that did not work? Record it, and keep track of how it did or did not affect you. Did you eventually find a drug in the same class that did work? Make sure your own records are clear, and if you want to, ask that a copy of your notes be included in your medical records, too. They may be helpful to your doctor should this question of step therapy come up.
Step therapy does seem to be a fair place to begin if a class of drugs is newly prescribed and the patient has no track record to rely on. But for someone who has already been through those steps, it seems like it could be medically harmful, if not downright cruel, to make them back up again. Like in Julie's case - it just makes no sense.
I expect we'll begin seeing much more of this denial of care, this imposition of cost controls through step therapy or other means, even when they are not appropriate. It's a form of rationing. It takes place today. Anticipate it, and keep records in preparation.
The steps you save may be your own.
Watch this video of Julie's story.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Learn more or join the conversation!
NEWSLETTER |
FORUM |
BIO |
TWITTER
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Photo © Microsoft Image Gallery
Excellent, fair-minded article. I don’t object to step-therapy either, in theory, but you’re right that it should be balanced with clinical considerations as well as whether in fact the patient already tried the step-therapy measures! Something similar happened to me once – had already tried the other drugs – doctor was able to clear it up with the insurance fairly easily. Fortunately I had a doctor willing to take the staff’s time to make the phone calls.
I was just denied coverage for a med I have been taking for years (Effexor) because of the “step therapy” policy. What a terrible thing to have happen. While I am working through this with my doctor and health insurer, I am paying out of pocket for my medication. I too agree that cost savings is important and I am willing to try any other SSRI that is cheaper and effective, but they don’t seem to want to cover any of the SSRIs. I am still investigating the options.
6/72011 – I was also denied a prescription call cymbalta by Univera in Buffalo NY by this so-call step therapy BS. Taking it for depression, and to help control some lower back pain following surgery. The managed care nurses and policy makers of Univera are cutting cost for who and at what cost, all for the wrong reasons. Not only do you have patients suffering,but the step-therapy drugs they want you to try are not even in the same drug family as Cymbalta, talk about educated human beings. Bottom line, all these cost cutting measures results in very poor healthcare services in society along with causing animosity between managed-care organizations and Doctors. We are heading back to pre-WWII where the patients had to pay for everything!!! Thanks gov officials for helping out the people of the USA !!!!!
Management of the prescription benefit is a contractual relationship between the managed care plan and the patient. In the detail of the Rx benefit language, there will be mention that the member will abide by whatever regulations the plan puts on usage. So Step Therapy (along with prior authorization, quantity limits, etc.) are easily implemented by the plan. (Contrast that with the medical benefit where the contractual relationship is between the physician provider and the plan, and the plan is bound (generally) by the inability to tell a physician how to practice medicine.)
Realize that the plan in the Rx benefit is not telling you you can’t have the drug. What it is is saying that you’ve agreed the plan can define medical necessity in this instance, and until the plan’s step therapy is adhered to, the plan doesn’t consider your medication medically necessary. Therefore, the plan has no legal obligation to reimburse you under your plan’s benefit.
USUALLY, when a step therapy such as this is implemented, there is a look back period and if the member has been on the drug during that period, the authorization is grandfathered in. However, the decision to grandfather is made by the plan and usually directly relates to the amount of grief the plan feels it will absorb by eliminating this look back.