Step therapy leaves some patients struggling to get medications

BEN: 5 ON YOUR HEALTH, THERE IS
A COMMON INSURANCE PRACTICE THAT
CAN DELAY MEDICATIONS FOR
PATIENTS WHO NEED THEM. IT’S CALLED STEP THERAPY. WE FIRST TOLD YOU ABOUT IT IN
2017. EMILY: DESPITE EFFORTS TO REFORM
THE PRACTICE HERE IN
MASSACHUSETTS, IT’S STILL
HAPPENING, FORCING SOME PATIENTS
TO JUMP THROUGH HOOPS TO GET THE
TREATMENT THEY NEED. THIS IS A FAMILIAR ROUTINE FOR
RICHARD PEZZILLO. GIVING HIMSELF MEDICINE THROUGH
AN I.V. TO TREAT HEMOPHILIA, A
GENETIC BLOOD DISORDER. >> IT SIMPLY MEANS YOU BLEED
LONGER, NOT FASTER. MY PARENTS JOKED AROUND ABOUT,
YOU KNOW, I WAS THE BUBBLE BOY
GROWING UP. NO CONTACT SPORTS. EMILY: AFTER SEVERAL DIFFERENT
MEDICATIONS DIDN’T WORK, RICHARD
FOUND ONE THAT DID. HE’S TAKEN IT THE LAST 10 YEARS
AND INSURANCE COVERED THE
SIGNIFICANT COST. BUT WHEN HIS HEALTH PLAN CHANGED
IN JANUARY, THAT COVERAGE WAS
THROWN INTO QUESTION. >> I GET A LETTER FROM MY
INSURANCE COMPANY STATING THAT
YOU WILL NOT HAVE ACCESS TO YOUR
TREATMENT UNLESS YOU HAVE THE
PROPER DOCUMENTATION THAT GOES
THROUGH THE REVIEW PROCESS. EMILY: WE FIRST TOLD YOU ABOUT
THIS PROCESS, STEP THERAPY, IN
2017. A PATIENT CAN BE PRESCRIBED OR
EVEN TAKING A DRUG THE INSURANCE
COMPANY MAY CONSIDER TOO NEW OR
EXPENSIVE. IN SOME CASES, THE PATIENT HAS
TO TRY OTHER DRUGS THAT MAY NOT
WORK BEFORE THE COMPANY WILL PAY
FOR THEIR ORIGINAL PRESCRIPTION. WHEN OUR FIRST STORY AIRED, 14
STATES HAD PASSED LEGISLATION TO
REFORM THE PROCESS. SINCE THEN, 13 MORE STATES HAVE
FOLLOWED SUIT. AND WHILE REFORM BILLS HAVE BEEN
INTRODUCED IN MASSACHUSETTS,
THEY’VE STALLED AT THE
STATEHOUSE. >> WE DON’T DO THESE
ARBITRARILY. EMILY: DR. NEIL MINKOFF IS THE
MEDICAL DIRECTOR OF THE
MASSACHUSETTS ASSOCIATION OF
HEALTH PLANS. HE SAYS A MAJORITY OF
PRESCRIPTIONS WRITTEN IN THE
STATE ARE APPROVED WITHOUT
ISSUE. AND FOR SOME EXPENSIVE SPECIALTY
MEDICINES, STEP THERAPY IS AN
APPROPRIATE PROCESS. >> WE’RE ASKING, FOR A DRUG THAT
WORKS FOR 85, 90% OF PATIENTS TO
USE THE LESS EXPENSIVE
ALTERNATIVE BEFORE MOVING TOWARD
THE BRANDED, MORE EXPENSIVE
ALTERNATIVE AS A WAY TO TRY TO REDUCE THE OVERALL POPULATION
HEALTH CARE COST. EMILY: MINKOFF ALSO SAYS EVERY
PLAN IN MASSACHUSETTS ALREADY
HAS A PROTOCOL TO HELP PATIENTS
STAY ON THEIR MEDICINES IF THEY
SWITCH PLANS. AND THEY SUPPORT LEGISLATION TO
GIVE PATIENTS A 30-DAY AUTOMATIC
REFILL, AS THEY GO THROUGH THE
STEP THERAPY PAPERWORK. RICHARD PEZZILLO SAYS IT TOOK
WEEKS TO GET HIS PAPERWORK IN
ORDER AND HIS TREATMENTS WERE
ULTIMATELY APPROVED. BUT GOING FORWARD, HE’LL HAVE TO
REPEAT THE PROCESS, TWICE A
YEAR. >> THE SAME THING AGAIN. AND THAT GIVES YOU ANXIETY. EMILY: A STEP THERAPY REFORM
BILL H

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