I have had psoriasis for 22 years and also suffer from complications of psoriatic arthritis in my back and hips for the past 14 years.
Four months ago, a miracle happened. My doctor prescribed a drug that not only significantly reduced my skin lesions, but also worked to control my arthritis.
For the first time in my life, I felt acceptable. I have hope.
This is the good news.
The bad news is that my insurance company refused to cover the cost of my prescribed medication and instead demanded that I first fail on “one or more” other, less-effective drugs.
My doctors and I know what the best treatment option is, but my health plan will not provide it.
It seems cruel and unfair that there is something to help me and others yet we cannot use it because a huge insurance company denies us that right.
I don't want to be a pariah anymore. I just want to have the medicine I need to look and feel like everyone else.
Maria Goldstein (left) and her representative
In 2013, nearly 67 percent of commercial insurers were using step therapy. 1
In 2013, 75 percent of large employers reported offering employees plans that use step therapy. 2
In a study comparing spending on schizophrenia medications in Georgia's Medicaid program, step therapy saved the state $19.62 per member per month. Cheaper drugs – savings all around. Right?
Wrong. The same study found that after the introduction of step therapy, the Medicaid program had to spend more money on outpatient services – $31.59 per member per month. That's because less-effective meds often led to higher health costs later. 3
It takes up to two hours per patient of precious staff time in doctors' offices to manage requests and appeals – taking critical time away from patient care. 8
Step therapy – also known as "fail first" – is a policy developed by health insurers to control costs. Sounds good so far. However, no matter what medication your doctor prescribes, if your insurer believes there's a preferred alternative, you are required to try that first. Only if that drug fails will the original prescription be filled. An insurer may insert several cheaper drugs and wait for them all to fail before agreeing to cover the drug your doctor originally prescribed. This process could take weeks. Or months. Meanwhile, what's happening to your health?
There is little oversight of step therapy. Generally, insurers do not have to prove the effectiveness of their step-therapy policies or even take into account the side effects of their substitute drugs.
Coalitions of patients, doctors and advocacy groups are forming around the country to pressure state and federal governments to ensure every person living with a chronic disease has access to effective treatments in a timely manner. See the map above for groups and activities near you. We invite you to join our mailing list and find out what we're doing and how you can help.
We're not selling anything and we're not going to sell your name to someone who is. All we want are more people to help us fight this battle. You and your doctor are the best judges of what kind of treatment you should receive – not your insurance company!