Many insurance companies are unwilling to pay for expensive medications if a cheaper and effective treatment is available.
Insurers will push for what is called step-therapy, where effective, cheaper drugs are favored instead of initially giving patients more expensive drugs.
Step-therapy is just one of the ways insurers are working to lower the overall cost of healthcare. However, one patient told Boston 25 News the practice literally made her sick.
Jen Melanson has been using the drug Enbrel to treat her rheumatoid arthritis for more than two years. Recently, Melanson found the drug wasn't working as well as it used to. She also learned she had a genetic disorder that caused her rheumatoid arthritis.
In January, she saw her doctor to switch up her medication.
"We found out there was a drug to treat rheumatoid arthritis that was the exact match for that genetic disease that I have, so it made sense that that was the drug my physician wanted to switch me to," said Melanson.
The drug her physician recommended is called Orencia, which, like every drug in it's class, costs thousands of dollars.
Her insurance company denied coverage, according to Melanson. A week later, she got a letter saying the company wanted her to try step-therapy.
"They want me to try one of two other drugs first under what they call their step therapy protocol," said Melanson. "[They said to] take it for a month or two, and if it didn't work my physician could document a failure and then I would be able to get the Orencia."
The step-therapy alternative for Melanson was a drug called Cimzia, where she was told to take it for about two months, and only if the drug failed would she be able to get the drug she was prescribed in the first place.
Melanson said not only did the Cimzia not work, but it also made her sicker. On Easter Sunday, she was admitted to the hospital.
"It was obvious to me that the longer I was not getting what I needed I was just continuing to get sicker and sicker," said Melanson.
The wait time for a step-therapy override is frustrating for both doctors and patients because often it does take weeks.
However, a bill in the Massachusetts State House aims at cutting the wait time under certain conditions.
The bill would require expedient overrides if, for example, a step-therapy drug could harm the patient, if it will likely not work, of if it is something that was tried on another insurance plan but failed.
Melanson finally got the Orencia approval letter two days after she was hospitalized. She said the drug is working.
"It's ridiculous to me that the insurance company can dictate what I should take for treatment and overrides what my physician feels I should be taking for treatment," said Melanson.
Cox Media Group