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Thursday / August 17.

Treatment Decisions Should Be Made By Doctors & Patients, Not Insurance Companies

Step Therapy is a practice used by insurance companies that requires patients to try and “fail” lower-cost medications before the medication actually prescribed by their doctor will be approved. This process is required regardless of the doctor’s best judgment or the patient’s reasons for choosing a particular medication. Step Therapy policies are not in the patient’s best interest, as they often create additional barriers to proper treatment.

I recently experienced the application of a Step Therapy policy first hand. I was diagnosed with rheumatoid arthritis (RA), an autoimmune condition, when I was just 25. Almost overnight I went from being a dual degree law student to barely being able to walk or even brush my teeth. It took more than a year to find the right combination of medications to get my RA under control so I could graduate.

“In my case, the choice of medication used to treat my RA is a decision that impacts my entire family.”

Today my husband and I have two little boys – ages four and two – and we’ve been considering another addition to our family. This means we have to get my RA under control on a treatment that is compatible with pregnancy, so my rheumatologist and I decided to switch me to a particular biologic. We chose a medication that I had taken in the past, so we know I’m not likely to have a bad reaction or side effects. There’s a good chance it will be effective, since it worked before. I’m also comfortable using an auto-injector to administer the medication. And, perhaps most importantly, there are at least five specific studies showing that this medication is safe for use while pregnant. In fact, I actually used it during my last pregnancy, so I am comfortable considering it for another pregnancy.

Unfortunately, because of my insurance company’s Step Therapy policy, the medication my rheumatologist and I carefully selected was denied. I was given a biologic I have never used before, so I don’t have any idea whether I’ll have a bad reaction or side effects. There’s no way to know if it will work other than to spend several months trying it. This medication is also administered with a real syringe, which I am far less comfortable with. And, unlike the biologic my rheumatologist and I selected, there are no specific studies on whether the biologic my insurance company chose is safe for pregnancy.

SB 17-203, sponsored by Senator Nancy Todd and Representatives Phillip Covarrubias and Chris Kennedy, would help protect patients like me. While it would not prohibit my insurance company from using a Step Therapy policy, it would at least require an override process for situations when the required step drug is problematic. And, if for some reason I had to change insurance plans in the future, SB 17-203 would protect me from having to go through this same process all over again.

In my case, the choice of medication used to treat my RA is a decision that impacts my entire family. As my story demonstrates, SB 17-203 is needed because treatment decisions are best made between the doctor and the patient – not by insurance companies.