Time to rein in step therapy

Too often this ‘fail first’ approach is inappropriate

BEING A MOM of three and a chronic disease patient is already tough enough – without any health insurance issues. I know this from firsthand experience living with a rare disease, managing the day- to- day of our family, along with our healthcare.

In 2012, I was diagnosed with rheumatoid arthritis after suffering from heart and multi-organ system failure. Around that same time, my 16-year-old son was diagnosed with a rare immune-deficiency disorder that doctors discovered was genetically passed to him from me. They realized that the rheumatoid arthritis was a secondary response to my own newly diagnosed immunodeficiency disorder.

The good news was that a promising treatment was available for the immunodeficiency, and it was also commonly used to treat rheumatoid arthritis. How exciting for me: a win-win in any book, especially since the treatment I was on at the time wasn’t working. My doctor said it made sense to switch to the more effective treatment and wrote me a prescription for it.

That was when my insurance company put the brakes on my medical care. I was required to try two other drugs before they would approve coverage for the treatment my doctor said was best for me.

This practice is known as “step therapy,” or, as we like to call it, “fail first.” It is an insurance industry tactic that essentially requires patients to use medicines the insurance company decides first and fail on those before being allowed to take the medicine prescribed by their doctors. While this is done by insurers as an attempt to control health care costs, it can often be applied inappropriately, with little regard to patient needs or medical history.   As a result, in many cases these requirements can delay appropriate treatment and ultimately increase costs, not lower them.

Many states have worked in recent years to bring changes to this policy for patients—and it’s time Massachusetts does the same. Too many patients like me continue to be forced to wait for treatment until step therapy is reined in.

On my doctor’s advice, I decided that rather than fight with my insurance provider, I would follow the insurance company’s “rules” and work through the step and fail process. It wasn’t what we wanted, but we were willing to go through this unpleasant process to finally get what I needed.  My case wasn’t the first time my medical team had seen a patient forced through step therapy,

After clearing the first hurdle of failing with two ineffective drugs, I was ready to begin the real treatment for my disease.

That’s when the insurance company abruptly changed the rules mid-game. I was told I had to try two additional medicines before qualifying for the more promising treatment.

It is extremely frustrating to know that there is a treatment with a high probability of working, but you can’t access it. This is not just wrong, it is immoral for patients and families, like mine.

There is a bill in Massachusetts that would keep this from happening to patients unnecessarily and I’m telling my story to show lawmakers that this is a real problem for real people in our state that needs to be fixed.   We need them to act so patients get the medicine they need to feel better, or in some cases stay alive.

Meet the Author

Jen Melanson

Independent patient advocate, Resident of Townsend
S.1235 and H.1853 have been introduced by Sen. Julian Cyr of Truro and Rep. Jennifer Benson of Lunenburg.  The bills, much like those that have passed in more than two dozen other states, put sensible parameters around the step therapy process.  The bill will help ensure that patients can’t be forced to try and fail on medications in certain situations, including if their doctor feels it’s not in the patient’s best medical interest, or if they’ve already tried and failed on that treatment.

I hope that more patients like me across the state who have suffered through this frustrating process will speak up, so that we can put doctors and patients back in charge of their medical care and pass common sense protections for patients while permitting the cost-saving benefits of step therapy when appropriate. I urge Massachusetts lawmakers to put patients first and finally pass step therapy reform this year.

Jen Melanson, who lives in Townsend, is an independent patient advocate.