I Encountered Step Therapy and Didn’t Know It
I was around the age of 22 trying to decide if I was going to try a biologic for the very first time. I had been apprehensive on trying an injection because of the potential side effects. I came to a point where I was even more frustrated with my psoriasis and an injection was about the only treatment I had not yet tried.
Weighing the benefits versus the side effects of a treatment
One day at a panel discussion I asked the question to 7 other women living with psoriasis, “Would you sacrifice 10 years of your life for an effective treatment…” With the rumors of cancers, sickness, and even death associated with certain drugs, it’s a question that’s not too far from reality. One of the ladies gave an answer I will never forget, “I decided to take biologics because it’s about the quality of life, not the quantity… And the days I was spending suffering without treatment was not a quality of life…” Her statement made me ponder what did a quality life look like to me? I was tired of suffering with psoriasis so I decided to give a biologic a try. My doctor wanted me to try Enbrel, but I had to try another medicine in a form of a pill and fail it before my insurance company would approve it. My doctor expressed that he didn’t want me on the required medicine because of side effects and he didn’t think it was appropriate for a woman of childbearing age. He and his medical team worked with the insurance company to fight against the requirement of me trying the first option before being approved for Enbrel.
How does step therapy work?
Last week I had a conversation with Amy Prentice the State Government Relations Manager from the NPF on step therapy. I didn’t realize what I had previously encountered with my doctor 8 years ago was step therapy, a form of prior authorization which requires patients to try cheaper treatment options before being approved for more expensive ones, “I think a lot of the times doctors know that a prescription will get denied. So a lot of times we see patients that are actually having to go through step therapy without even knowing it,” reveals Amy.
In a general sense, the process doesn’t sound that bad. You try a medicine and if it fails you move on to the next, unfortunately, it’s not that simple. The downside of this process is it’s time-consuming, exposes individuals to unnecessary side effects, and delays a patients treatment success rate. Many of the cheaper options are less effective and have lower success rates.
During this particular time, I had had psoriasis for over a decade and had used an array of treatments ranging from topical treatments, light therapy, to pills. When it was time to consider a biologic I had tried most of the drugs required other than the one which my doctor was fighting against. In some cases the insurance company will require a patient to try SEVERAL drugs before approving a more expensive drug. Not sure exactly what my doctor did, but he was able to bypass the requirement of me having to use the required treatment, thus I was able to start using Enbrel. This process took several months. Have you encountered step therapy?
What can I do about step therapy?
Check your formularies
A formulary is a list of prescription drugs covered by an insurance company. “Patients should first, look at their formularies for their health insurance plans and the drug treatments they’re on to see a step therapy protocols are required,” Amy advises.
Keep up with your medical records
Thus far I’ve seen at least 15 doctors for my psoriasis. Most of them were not in the same hospital network so it was my responsibility to make sure my records were sent to my newest doctor. Most times when visiting a new doctor they are unaware of what you previously have tried or dealt with, and unfortunately, it’s the responsibility of the patient to ensure the new doctor receives medical history. Keeping up with your records will avoid you having to restart a step therapy treatment plan with medicines you may have already tried, with a new doctor.
The NPF Patient Navigation center can help with appeals
An insurance company may deny your request for a certain treatment. You can appeal the denial. Amy suggest reaching out to the NPF Patient Navigation Center (PNC) if one has been denied, “If there’s any question at all, our patient navigation center is fully aware of step therapy… whether it be to find out if there is a law in place [in a specific state], how one can appeal, how to fill out appeal forms, how to submit forms, really any type of question. Uh, the PNC is always a great resource and can help patients through that process.”