“My doctor wanted me to try Benlysta, a drug that is FDA approved to treat lupus; however, my insurance denied the approval for the medication. They said I had to “try and fail” other off-label medications like Iruman and methotrexate. One medication made my white cells tank, the other made my hair fall out, and neither helped my lupus.” -Lupus Patient
What Is Step Therapy
Step therapy, or the “fail first” requirement, is a process used by health insurance companies to control costs. Like the name sounds, step therapy creates additional “steps” that a patient needs to take before he or she can attain the medication the doctor originally recommended and prescribed. On average, step therapy requires a patient to try more than one medication that the insurance (not the doctor) determines is appropriate to treat them. These alternatives are often generic forms of much lower costing medications, that are more accessible, and overall easier to distribute.
If you are a lupus patient reading this, the above information probably sounds very familiar, particularly, if your doctor has recommended you try some of the newer (and more expensive) therapies, like the lupus “shiny penny” Benlysta. Benlysta is the first FDA approved medication specifically designed to treat lupus in over 50 years. It is a fantastic option for many lupus patients, if your insurance will allow you to have it.
Why Step Therapy Is A Problem
The problem with step therapy is that the process can be arduous, and often detrimental to the patients health. Reason being, the patient has to endure months (sometimes years) of trying and failing off-label medications before his or her health insurance will allow them to “step up.”
This process is physically and financially taxing, invalidating, and emotionally frustrating to the patient who has to “prove” that they need the medication that was prescribed by their doctor. It places all the power in the hands of the insurance companies, like they know more than the person who went to medical school and knows the nuances of your medical history.
It is evident that insurance companies:
Hope patients grow weary and give up asking for their doctor to re-submit approval for the original prescription,
Or by some miraculous fate, hope the patient will be okay with the sub-par medication.
If this is not the case, the insurance company isn’t thrilled because it means one step closer to the more expensive drug that they didn’t want to pay for. Albeit the right option for you, but the wrong option for them.
How Common Is It?
Unfortunately, step therapy is common in both private and public health insurers. According to The American Journal of Managed Care, a 2014 report stated that nearly 75 percent of large employers in the US have health care plans that implemented step therapy protocols. Furthermore, a 2018 analysis by the journal of Health Affairs discovered that among 1,208 coverage decisions by the top health insurers in the US, 63% required a patient to step through one drug, 37% required a patient to step through two drugs, and 15% included at least three step throughs. Other studies have suggested that as much as 75% of patients have to "try and fail" at least one medication on average.
You may be thinking to yourself, this is criminal! How do they get away with this? If I may for a moment remove myself from my patient high horse and look at this objectively, I can see how in some cases step therapy can make sense. For instance, for those who have an acute issue, like a virus or infection, and need antibiotics, having the insurance shift to a generic form of the medication may be the appropriate cost-saving measure. However, (here I am back on my patient high horse) for those living with a chronic illness like lupus, these “insurance overwrites” can lead to more issues, more doctors appointments, more hospital visits, which - HELLO- is overall MORE expensive.
I mean, come on.
Stand Up For Your Rights
If you have been affected by step therapy, it is time to speak up. There is a fantastic patient advocacy page called failfirsthurts.org. As their website states, “Patients need a voice in all conversations that relate to our access to treatment, safety, or the quality of our care. This community is made up of patients living with diverse chronic illnesses, including rheumatoid arthritis, lupus, and psoriasis, and the people who care about them.”
Article By:
Kelli Roseta
**All resources provided by this blog are for informational purposes only, not to replace the advice of a medical professional. Kelli encourages you to always contact your medical provider with any specific questions or concerns regarding your illness. All intellectual property and content on this site and in this blog is owned by morethanlupus.com. This includes materials protected by copyright, trademark, or patent laws. Copyright, More Than Lupus 2019.
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