When a patient goes to their personal doctor because they are experiencing a significant health struggle, they do so with the trust that their doctor will recommend a treatment based on a specific understanding of the unique complexities of their condition. All too frequently, however, the treatment agreed between patient and doctor is being delayed if not wholly pre-empted by a process imposed by insurance companies known as “step therapy.” Step therapy is a protocol in which insurance companies use predetermined criteria to force patients to try less expensive drug treatments prior that which is prescribed by their doctors. As a result, patients who are already struggling with often very immediate needs are forced to endure a process of trial-and-error with medications that their own doctor feels will be less effective if not counterproductive, all for the sake of cutting costs.
Medication has always proven to be an especially complex issue for brain injury survivors. Two patients with what, to an outsider, would seem to be similar if not the same injuries can experience wildly different results from the same medication. A neurologist or neuropsychiatrist who works directly with a patient can consider the myriad variables that a “one size fits all” step therapy protocol never could in determining the appropriateness of a prescription. Yet patients are being forced to “fail first” on one or more cheaper treatments before being able to have the appropriate treatment covered by their insurance. People are suffering because of this, but the good news is that the Arizona legislature has a chance to fix this and make things right.
Step therapy protocols can be an exhausting process for patients. There are currently too many appeals to file and roadblocks to maneuver for patients, not to mention the negative psychological effects that come with needlessly cycling through ineffective medications that are required by these protocols. Sen. Nancy Barto’s bill, HB2420, helps to fix these problems with smart compromises that will put the patient’s health and well-being as the top priority. HB2420 will allow patients to better use the existing medical exemptions offered by their insurer or pharmacy benefit manager in order to “skip the line” and get directly to the medicine that will work for them. These exemptions are reasonable, such as if the patient would likely have an adverse reaction to the prescription drug, if the prescription is expected to be ineffective, or if the patient had used the prescription drug previously and discontinued its use.
The bill also lays out guidelines to keep insurance companies from dragging their feet on responding to these exemption requests. There will no longer be patients forced to stick with a drug that is not working for weeks and months, as under this bill, insurance companies must respond to exemption requests within 72 hours (or 24 hours in cases of emergency). If they do not respond, the exemption will be automatically granted. Considering the negative and damaging effects an inappropriate medication can have on a brain injury survivor, it is crucial that a patient and their physician be able to forego a step therapy protocol when needed and to have an expedient process for doing so.
Any health plan that has a step therapy program should be based on what the doctor recommends and what works for the patient, not on what will save their insurance company the most money. Dozens of other states around the country have passed similar pieces of legislation, because patients of all kinds, whether it be for brain injury, blood disorders, cancer, or any other disease that requires a delicate level of treatment and care, have asked their elected officials for help, and their elected officials have answered the call. Arizona should be next.
Will Grove is a resource facilitation specialist for the Brain Injury Alliance of Arizona.