You know the old saying that if March comes in like a lion, it goes out like a lamb (and vice versa). Well, here in the North East of the US, the weather has shifted from freezing and snow one day to 70 degree weather the next. We are in “lamb” mode! While I enjoy diversity and then gorgeous sunshine, my joints do not. I ache. The pain is not excruciating but stairs, the shower, and walking down the hallway at work are kicking my butt. Thankfully, my trusty biologic drug worked it’s magic and I’m moving much easier today. I truly hate injecting myself weekly, but I have come to depend on my biologic drug to get me over these humps. I’m grateful my insurance covers it and that after 4 failures, I am on a drug that really works for me.
What is step therapy, you ask? Well, let me explain. Step therapy is an insurance company practice that states before starting a drug therapy program, for a medical condition with the most cost-effective and safest drug and only progressing to other more costly therapy only if necessary. The guidelines are created by physicians and pharmacists. I’ve had the same insurance since 1994, so that insurance company had no issue with my climbing the step therapy ladder over the course of 7 years until I found the right drug. I have issue with the fact that I lived in excruciating pain for 7 years before finding the right drug, by the way, but that’s another rant. See you have to prove the lower tier/cost-effective drugs don’t work by “failing”. I’m not going to name those drugs, because honestly, they are amazing drugs. They just didn’t work for me (and one put me into anaphylaxis), but millions of other people do very well on those biologics. I never knew about step therapy, and honestly thought this process of “failing” drugs was part of the process of living with an autoimmune arthritis disease. I knew I had to get pre-authorizations and it took time to gain approval. My current biologic drug is considered Tier III and I had to fail Tiers I and II prior to getting approval through my present insurance plan. So in July, when I have to switch insurance companies, there is a serious chance that my Tier III drug will be rejected because the company does not have “proof” that it works better than a cheaper biologic drug. I’m willing to bet they will approve a Tier I drug pretty quickly. The sad part, is that there are many rheumatologists who probably know that a patient may not do well on certain drugs, but they have to recommend the more cost-effective medication and have patients spend months struggling on the wrong drug. I, for example, failed on a Tier I drug early on. It was my second biologic. It did nothing for me. It was so obvious that it wasn’t working, but I wasn’t on it long enough for the insurance company to approve a Tier II drug, so my rheumatologist had me injecting a weekly drug twice a week to try to compensate. Honestly, failing these drugs made me feel like a failure. Luckily, I met a amazing patient advocate named Leslie who pointed out to me that I didn’t fail the drug, the drug failed me.
I have two friends who recently had to change insurance companies. One had a doctor who helped them fight it, but it took a long time to get approval from the new company. The other’s doctor was also new (b/c her previous doctor was not in her plan) and was fine with trying the Tier I drug again. Both patients have autoimmune arthritis and both have suffered needlessly for a few months and have seen their diseases progress on drugs that were not “approved” by their new insurance. Hearing their struggles both infuriates me and scares me to death. It’s only March, but I’m already trying to get my ducks in order.
First, I spoke with my rheumatologist. I told her my situation and my fear. She seemed shocked to know that I was aware of step therapy and I told her about IFAA’s work to “Modernize Step Therapy” since the current model has not changed since the 1980’s. She assured me her office will fight for me and provide the documentation I need, but she can’t guarantee it will be approved.
Second, I downloaded the current regulations regarding insurance and step therapy for my state (thanks to Tiffany Westrich for the information): http://cqrcengage.com/painmanagement/legislation
I know that Indiana has recently changed laws regarding step therapy, but in my state, there is not a regulation on the books regarding this old fashioned practice.
Third, I am going to try to speak with the representative in charge of making this switch for my company. I’m going to see if the new insurance company can help me identify the information I need to get and a timeline for approval.
I’m preparing for war just in case. I am petrified what will happen to me if I can no longer take my Tier III biologic drug. The thought of the burning pain, the swollen/red joints, the severe fatigue that just about cripples me scares me more than I can put into words. I still have some of these symptoms now, but in a much milder version with some flares. My disease is bad, but no where near as bad as it was prior to taking my current meds. I force myself to work full-time to have insurance benefits so I can afford my medication. I always say I work to avoid becoming disabled.
This July, I will be the lion fighting for what I need to a quality of life that I deserve. Hey insurance provider….get ready to hear me roar!!!!!!!
***To learn more about step therapy, check out the work that IFAA is doing with Lupus & Allied Diseases Association to Modernize Step Therapy. http://www.ifautoimmunearthritis.org/ethics-of-step-therapy.html
Two weeks ago I was present at the Indiana statehouse lobbying for a bill that gives control of step therapy to the doctor as opposed to the insurance company. That bill passed both houses unanimously and is awaiting the signature of the Governor. Step therapy as you explained is one of the more important battles we with chronic disease fight. Thank you for your lovely post. I agree with you 100%.
Thank you! I was thrilled when I heard about Indiana. Hoping Pennsylvania is next!