What is Step Therapy?
All medications affect different people – even when those people have the same diagnosis – in different ways. This means that side effects and the level of effectiveness vary significantly from one person to another. Because of this, it is extremely important to be able to access the medication or procedure prescribed by your doctor – the one that the doctor believes will work best for you.
Unfortunately, any time your doctor prescribes a prescription drug that happens to be more expensive than some others, many insurance companies will require you to go through step therapy, also known as “fail first.” The prescription drug could be more expensive because it is relatively new but may work much better for your medical condition than older drugs.
Step therapy requires you to try one or more insurer-preferred medications unsuccessfully before the insurance company will cover the doctor-recommended medication. In other situations, your physician may believe you need a specific medical procedure. Your insurance company steps in and says you must try other (less expensive) therapies before it pays for the one your doctor recommends.
This can be extremely frustrating, making you spend months taking drugs that are not what your doctor believes you actually need or trying one procedure and then another before you can have the prescribed procedure done. If you find yourself stuck in this seemingly endless loop, it could be time to speak to a knowledgeable insurance denial attorney from the Law Offices of Scott Glovsky. Attorney Glovsky is ready to fight on your behalf to help you get the drug or treatment your doctor believes is best for you.
Do All Insurers Use Step Therapy?
Virtually all insurance companies use step therapy as a way to control costs. This means that if a medication exists that is less expensive than what your doctor prescribed, they often insist that you try that drug first. Medications in step one are usually covered without a problem and are often generic.
You must usually begin at step one and try the drug until you and your doctor deem it is not working for your medical condition. Generally, two or three steps are required before the drug your doctor prescribed is approved. Depending on the medication, you may have to take it for an entire month or, if you immediately have adverse side effects, you may not have to take a drug for the whole month. For example, certain statin drugs – for lowering cholesterol – are more expensive than others, yet some statins cause severe muscle aches in some patients.
Your doctor might prescribe brand-name atorvastatin (Lipitor–$658 for 30 40-mg tablets or Atorvaliq–$230 for a month), but because they are expensive, your insurer could require a generic for Lipitor (atorvastatin) or may require you to begin by taking generic simvastatin, then Simcor or Zocor before approving Lipitor. This can be frustrating because the (higher cost) brand-name Lipitor statin has been shown to reduce cholesterol faster and by more than the other, cheaper statins.
Another common example is back surgery. Your doctor may prescribe an expensive procedure that has proven effective for your condition, but your health insurance company may require you to try physical therapy, then a cortisone shot, and so on prior to approving an expensive surgery.
What is Off-Label Medication Use?
Step therapy is usually used for brand-name medications that have more affordable substitutes but can be used because the insurer believes the medication is not the first choice for your symptoms or because the drug is being used off-label. Doctors prescribe drugs for off-label use fairly often; the FDA may have approved the drug for a specific purpose, but doctors have found that the drug has other uses that are not specifically described on the drug’s packaging.
For example, Trazodone is an older medication used to manage and treat depression. Doctors often prescribe the drug as a sleep medication, particularly for older people, even though this is an off-label use. An insurance company might require you to take a less expensive sleep medication, or a medication that is FDA-approved specifically to help you sleep, even if Trazodone works well for you.
What is a Preferred Medication List?
Usually, you can go to your insurer’s website to find the preferred medication list, usually called its “formulary.” This list should tell you whether a specific medication is covered or excluded, whether it will require step therapy, whether you can take the drug off-label, and if there are limits on how much or how often you can get the drug. Preferred brand drugs are brand-name medications that are considered the best value for a specific condition.
Drugs are compared to other brand-name drugs that treat the same condition, and one is selected over the others based on clinical efficacy and financial value. Unfortunately, too often these insurance company “medical” or “pharmacy” policies are out-of-date with the latest clinical research and generally accepted standards of care, Most insurers now have “tiers” for drugs, with preferred drugs in tier one and drugs that are rarely covered or will require step therapy in tier five. Tier one often includes generic medications. Tier five drugs are considered “specialty” drugs to treat conditions like cancer and may be generic or brand names. If an insurer approves a tier-five drug, you will likely pay at least 33 percent of the retail cost of the drug.
What is the Cost to the Patient for Step Therapy?
Policies that restrict access to doctor-prescribed medication often lead to negative outcomes for patients. In some situations, a step therapy prescription can lead to hospitalization or a trip to the ER. Step therapy can delay necessary treatment, leading to adverse reactions that can harm the patient and ultimately increase health care costs. For those with rare diseases, the impact of step therapy can be especially severe.
These patients often endure diagnostic journeys that can last for years before finding a treatment that works, which should cause insurers to make an exception on step therapy policies. Mental health medications should also have exceptions due to the danger of step medication causing an individual’s mental health to worsen.
Is There Any Way to Avoid Step Therapy or Insurance-Prescribed Care?
Insurance companies typically implement step therapy and prior authorization protocols as utilization-management strategies to limit their costs. This is in direct conflict with physicians whose goals are to safeguard patients from unnecessary risks and delays while bringing their patients back to a healthier state as soon as possible. States are beginning to implement their own requirements for insurance companies, which are meant to protect patients while allowing them to receive the treatment or medications their doctors believe they need.
Some states may now require insurance companies to provide a simple exception process for providers and patients to challenge the use of step therapy while establishing clear, expedited timelines for decisions as well as protocols for emergency situations. You can download California’s step therapy exception form called the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form here. State step therapy protocols should include the following exceptions (although many do not):
- The required drug could cause an adverse reaction.
- The required drug is expected to be ineffective for a specific patient.
- The patient has tried the required step therapy drugs while under a different insurance company, so they should not have to do so again.
- The required step therapy drug is not in the best interests of the patient who needs immediate treatment as prescribed by his or her doctor.
- The patient is stable on his or her current drug, approved by a prior insurance company.
Getting the Help You Need from the Law Offices of Scott Glovsky
Many people simply give up out of frustration and let their insurance company tell them what procedure, treatment, or prescription drug they need. If your insurer requires step therapy, a different treatment or procedure, or has outright denied a medical procedure, treatment, or prescription drug, you need an attorney who is ready and eminently qualified to fight on your behalf. Attorney Scott Glovsky and his legal team are ready to stand up to your insurance company and tell them, “No more.”
Scott initially worked in large law firms for big insurance companies when he began his legal career, which gives him exceptional insights into how these companies think and respond. Scott then founded his own firm in 1999, vowing to hold major corporations accountable for placing their bottom-line profits ahead of people’s lives. If you are ready for someone to make a difference in your life and change the system, contact the Law Offices of Scott Glovsky today.