Stepping Up to Step Therapy
I used to love to get mail as a kid. Each envelope with my name on it was greeted with as much enthusiasm as an excited puppy. Nowadays, however, my mailbox is usually full of boring bills–or worse—insurance denials. If you’ve haven’t had this happen to you, you may not be familiar with step therapy.
Getting medications denied by my insurance provider is something I have grown accustomed to. Medicine for psoriasis tends to be pretty expensive, so I have often had to jump through multiple hoops to be able to access it. For the first few years, I would see a denial and either blindly comply with what they wanted me to take instead, or I would shut down. Neither of these decisions helped me in the long run, but I am wiser(ish) now.
Don’t get discouraged
When you get that notification that the medicine your provider prescribed was denied, try not to get down. I am fairly certain that insurance companies deny initial request in hopes that they can get out of paying. After all, they are a business and we should not forget that. Always talk to your doctor if you get a dreaded denial letter to see if they agree with the proposed medication that the insurance company is willing to cover.
Dig a little deeper
Call the number on your letter and ask for the credentials of the person who made the determination of coverage. Years of speaking with other patients has enlightened me on this subject. I have heard cases where the insurance company will either flat out refuse to give credentials or a name, or they have found out that the doctor that thought step therapy was the best way to go had no actual training on our disease! Case and point: one psoriasis patient was denied a biologic medicine and told to go through a gamut of less effective medicines by a GYNECOLOGIST. Really? A doctor that specializes in women’s health is going to tell me what is best for my complex autoinflammatory disease? Don’t get me wrong—I am sure he/she is well educated, but his/her specialty does not usually cover my disease.
Stepping it up! Fight back
Start your appeals process as soon as you can. If you have a good doctor/specialist, they will help fight with you by providing chart notes and an appeal letter. This is really important. I have changed doctors because of this. One doctor took 4 weeks to send over chart notes to my insurance provider, which left me in an agonizing state of flare. This isn’t ok. Yes, docs are busy and often overworked, but no one should have to suffer due to paperwork.
Know your resources
If you need additional help with an appeal, the National Psoriasis Foundation’s Patient Navigation Center is a great asset. While I was waiting on my former doctor to help me, I reached out to NPF and got some really useful information. They were able to draft a letter that better explained my disease and why the medicines they proposed I use instead were not right for me.
Make a change
Finally, if step therapy gets you as fired up as it does me—do something about it! Write to your representatives about legislation surrounding step therapy. Some states have already passed bills safeguarding the patient-provider relationship, and many others have bills in motion. I have never before realized what a huge deal it is to pay attention to who is in office. I recently visited my capitol to share my story and advocate against step therapy, but unfortunately the bill got shot down almost immediately.
Health insurance is a hot button issue now, but I hope that I will see real change in this area soon. There is no perfect health system, but all patients should have access to affordable life-changing medicines.