Explain it Like I'm 5: Pharmacy Part 2 - Step Therapy
Part 2 of my 3 part series on pharmacy benefits
Step therapy is another form of “Utilization Management”, along with prior authorization requirements. Here is the definition:
If a health plan uses step therapy for certain drugs, it means that a patient can be required to try a lower cost prescription drug that treats a given condition before “stepping up” to a similar-acting, but more expensive drug. The health plan won't cover the more expensive drug until the lower-cost medication has failed to treat the patient's condition. Other names for step therapy are “step protocol” and “fail first requirements.”
Step therapy is a very common cost-control strategy. Step therapy generally saves money for both the patient and the health plan.
Allegedly, this can be beneficial to the patient and insurer to save money. And there is something to be said about trying out a cheaper medication to see if it works.
But, like everything in capitalism, the insurers use it to harm patients so they can make profits.
True story, a close friend of mine had to deal with this. The generic medication stopped working. They needed the name brand. She had been on the name brand with no problems on the same insurance for years. All of a sudden, the insurance company refused to cover the medication.
This is a condition where if they do not get effective medical treatment, they will become very sick and die. It’s been a fight every single year since the change.
With the rising cost of healthcare, insurers will be utilizing these tactics more and more.
I posted the formulary in my last newsletter, and if you go through the formulary, it will tell you what medications require step therapy. I’m sure we will see the costs skyrocket as trump toys with the idea of tariffs on medications. So insurers have an incentive to make sure they cover as little as possible.
Let’s look into what it is and how you can get around it.
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What healthcare advocates say about step therapy
Step therapy can be a danger to the health and well-being of the person taking the medication, and result in a worsening of symptoms and undermining the decisions made between individuals and their health care providers. Instead, policies should maintain access to provider-recommended medications and should specifically prohibit step therapy for psychiatric medications, or, at a minimum, establish clear, rapid timelines for insurer responses to requests for exceptions and ensure that people who have previously used a medication do not have to switch.
Sorry about your open, oozing sores, kids, but I need a new yacht. (Created by me with Canva)
As someone who has been through the “Medi-go-round”, it took 10 years to get proper treatment, and I was on 9 different medications before I found the right combination. The medications had terrible side effects. One made me bipolar (Not joking or trying to be hyperbolic, my mood was cycling constantly. My spouse is bipolar, I have seen it), one made all of my joints hurt, and the rest turned me into a zombie. I could not imagine doing that again.
And the insurers require weeks or months of treatment before they will cover the requested medication. Many physicians rightfully claim that step therapy is out of control, doesn’t actually control cost, and is actively harmful to patients.
Just a couple of happy pills. Created with Canva.
If you’ve struggled to find the right medication, you already know.
There is a reason step therapy is also called “Fail First” therapy. The first treatment needs to “fail” before they will cover another medication. So, what does this “failing” look like?
The consequences of delaying appropriate treatment can be even greater for patients with rare diseases. Consider the Maxwell family, patients of co-author Dr. Burgy: Virginia Maxwell was born with pityriasis rubra pilaris (PRP), a rare genetic auto-immune disorder that causes constant inflammation and scaling of the skin, leading to painful bleeding sores and, ultimately, infections. Virginia and her dermatologists worked closely together, and over the years found an injectable drug that effectively controls her condition. Her children have PRP as well, and one son was eventually approved for the same injectable drug but only after he had tried and failed treatments that had also been ineffective for his mother. During that delay, his condition deteriorated so severely that he missed school for a month and was unable to walk or sit still because his skin was painfully open and bleeding with sores.
This is what it looks like. And this is a child. Read that bolded section again. A child was unable to walk and was covered in bleeding sores, all because the company decided to prioritize profits over the health of their patients. And don’t take my word for it. Read this heartbreaking story from Qasim Rashid, (who you should follow.)
The recommended biologic promised not a cure, but a chance at living a healthy life. Our insurance rejected us outright reasoning that we hadn’t tried other medications first—a policy called "step therapy." Despite our daughter’s life threatening condition, they wanted us to try every other variation of every other possible medication—knowing full well they would likely fail just as much and make our daughter suffer, vomit, bleed, and lose weight. But that did not matter to them, because that was the preferable path to ensure they “maximized shareholder value.”
Emphasis added.
Again, this is a child. This child weighed 30 lbs and was critically ill. But, due to the step therapy requirements, this child suffered needlessly because shareholders need another fucking yacht. And believe me, it will get worse with Dr. “Moneybags” Oz, who made millions on Medicare Advantage plans, has an incentive to make sure those corporate profits and stocks are sky-high. And if you think this fucking scumbag actually cares about people because he’s a doctor, he had this to say:
"Schools are a very appetizing opportunity. I just saw a nice piece in The Lancet arguing the opening of schools may only cost us 2–3 percent in terms of total mortality. Any life is a life lost but to get every child back into a school where they are safely being educated, being fed, and making the most of their lives, with the theoretical risk on the back side, might be tradeoff some folks would consider."
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And yes, people thought this he didn’t mean 2-3% of kids in school dying, but he just meant overall mortality rates. I don’t know who needs to hear this, but even if he didn’t mean children, he is a fucking ghoul. I understand being a doctor can make you like that because you see death every day, so I understand. However, this is why I want him nowhere near our health insurance. Because it’s acceptable to have loss of life if it serves our corporate overlords.
So, if you think he’s going to give a shit about more dead Americans, I got a house on the moon to sell you. Once he decides to do away with the guardrails Medicare has on the advantage plans (Which are much more well regulated than the insurance you and I have access to), we will see cuts to benefits and increases in out-of-pocket expenses.
What to do if you’re required to do Step Therapy
So, step therapy is essentially a prior authorization. You can get a medical exception with your insurance. Here is a handy, though slightly insurance-ass-kissing, article to help you out. Your insurance company website does have a list of drugs that require step therapy, so you can double-check to see if the medication requires it when you speak to a doctor. The biggest piece of advice I can give is to get ahead of it. So if your doctor discusses a medication with you, you can utilize the website to get the information ahead of time, and it will make the process go more smoothly.
Obviously, it’s a lot of hoops to jump through, so you definitely want to make sure you understand the steps (Hey, now is a great time to subscribe to my substack for my ELI5 series!). Unfortunately, as this is a capitalist hellscape, and you shouldn’t be forced to jump through hoops just to live, but hopefully this will help make it easier.
Stay safe! Please keep an eye out for part 3 on PBMs either later in the week or early next week.
~ Ana the insurance demon.
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