Health

How to Navigate "Step Therapy" and Other Treatment Obstacles Associated with Chronic Conditions

Unfortunately, insurance hiccups can cause challenges for patients. Your physician may be able to help you appeal coverage denials.

10/22/2019

A diagnosis of a chronic condition such as Crohn’s disease, ulcerative colitis, cancer or diabetes can bring a swirl of thoughts and emotions. There may be relief at finding an explanation for bothersome symptoms, but that relief is often quickly overshadowed by insurance issues, financial concerns and worry about the future.

If you’ve recently received a chronic diagnosis, take it one step at a time to navigate the road ahead. Here are some tips:

Understand Your Condition

Arming yourself with information is critical when you receive a life-altering diagnosis. It’s important to understand everything you can about the condition, including known causes, symptoms you may experience, what you can expect as the disease progresses and more.

Identify Treatment Options

A big part of your research will likely involve your treatment options. If your doctor has outlined multiple options for treatment, you’ll want to investigate each one thoroughly so you can understand the benefits and risks, as well as deciding which option is the best fit for your particular circumstances. You’ll also want to confirm that your treatment is covered by your health insurance and at what level.

Handle Insurance Issues

Most people assume that if they have health coverage, they can count on at least a portion of the treatments and medications their doctor recommends being covered. In many cases, that’s true, although the exact coverages depend on variables like your plan, deductible and more.

However, there are also some circumstances in which you may experience a delay before you’re able to follow your doctor’s treatment orders. One example is step therapy – a protocol sometimes used by health insurance companies that requires patients to try and fail on one or more lower cost medications before they will provide coverage for the medication originally prescribed by the patient’s provider.

Step therapy is an aggravating insurance obstacle for those with chronic conditions.
photo credit: CDC

Step therapy is also known as “fail first” because it requires a patient to fail on an insurer-preferred drug first. Unfortunately, for patients with inflammatory bowel diseases (IBD), like Crohn’s disease and ulcerative colitis, this protocol may result in worsened health outcomes. A survey by the Crohn’s & Colitis Foundation found that as many as 40 percent of IBD patients had been subject to step therapy, and 58 percent of those patients were required to fail two or more drugs before being granted access to the drug their doctor originally prescribed.

“During these delays in optimal treatment, patients are at risk, not only for their physical well-being, but also for their quality of life,” said Dr. Ross Maltz, co-chair of the Government and Industry Affairs Committee of the Crohn’s & Colitis Foundation’s National Scientific Advisory Committee.

“In some instances, insurance policies can impede patient access to the care they need and affect the patient and provider decision-making process.”

Groups are working to change this process through legislative reform but, in the meantime, if you are subject to a step therapy requirement by your insurance provider, you can appeal. The best approach is to work with your doctor to prepare a written letter that contains:

·        A clear statement that you are appealing a denial of coverage for your prescribed medication

·        The name of the medication that was denied

·        A detailed explanation of previous treatments or factors that led your doctor to prescribe the denied medication

·        Any studies or evidence that support the use of the prescribed medication

·        The specific health risks you experience now or may in the future without the medication that was originally prescribed

·        A clearly stated request for approval of the specific prescription, including the medication name and dosage

To find more information and resources, visit crohnscolitisfoundation.org/steptherapy.

 

Family Features | Feature image credit: Consumer Reports

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