Her son, Michael, has multiple chronic illnesses, Asperger's syndrome -- a form of autism -- asthma, ADHD and Gastroesophageal reflux disease (GERD). He's on numerous medications and the family spent years finding the right combination of drugs that interacted with one another properly and also managed his symptoms.
The family tried generics and different versions of them at her original insurance company's request, only to find they did not work before moving to newer, name brand medications.
But the time already spent trying those medications that did not work was not considered under the new insurance plan.
"We had to do the process all over again," she said.
It's a practice called step therapy -- patients must start with the most cost-effective or safest drug, moving to more costly or risky therapy only after those treatments fail. It's a way for insurers to control costs and minimize risks.
And the vast majority of the time, it makes sense for an insurer to ask doctors and patients to go through the process. But there are instances when exemptions are needed, advocates say.
For example, after
But he kept coughing. After several months, they put Michael under to get a better look at his lungs. That's when they found that the coughing had nothing to do with his asthma. The drug mixture had caused multiple stomach ulcers to form, which were producing acid reflux and causing him to cough.
"I was so angry," Heaton said. "We decided that we'd pay out of pocket before we changed prescriptions again."
That experience is what brought her to
The legislation would allow exceptions from step-therapy protocols when inappropriate. It would give the patient immediate coverage of the prescribed drug if there is proper documentation.
It's supported by the
"Although this legislation is well-intended, almost everything being proposed is already covered by existing federal and state laws or regulations. Additional legislation could create a confusing overlap of these regulations,"
The insurer added it has been involved in discussions with the bill's advocates to address concerns while ensuring that health plans can continue to administer appropriate, scientifically based step-therapy programs.
"In terms of step therapy, these protocols are understandable to have set for the usual patient," said Dr.
Brooks has one patient whom he has been working with for more than a year to find medications to properly mitigate arthritis symptoms. But then the patient switched insurance companies and the insurer had a different set of preferred medications, so the patient wasn't allowed to stay on the drugs.
Brooks has the medical records and the often yearslong history with patients. It's important that insurers allow for exemptions so that health care professionals can properly care for their patients, he said -- especially when being taken off a working medication could harm a patient or stop progress, such as in the case of patients who suffer from seizures or a mental illness.
Brooks said physicians understand drug costs are high and insurers are trying to contain them. But the system needs to be altered, he said.
"We need the ability to, in an expedited way, get answers within a reasonable amount of time," he said.
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