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Insurance Company Practice Of 'Fail First' Called Into Question

Todd Bookman

“I have Crohn’s Disease, I have diabetes, high blood pressure, high triglycerides, and I had a stroke. From all of this, I am on medication for depression as well.”

Chalk it up to bad genes: Amanda St-Amour struggles with a lot of health conditions.

She’s 30, lives in Merrimack, and pulls out a small laundry basket full of pill bottles.

“Basically, I take about 1, 2, 3…15 pills a morning.”

Recently, one pill has gone missing from the stack. It’s a drug called Trilipix, which St-Amour has taken for years to keep her triglyceride levels down.

When she switched jobs recently, she also switched health insurance. The new insurer refused to cover it, explaining its decision in a letter.

“We gave individual consideration based on the material available to us. We could not approve coverage of this service because you did not meet the medical necessity criteria required for coverage of Trilipix because there was no documented treatment failure with two covered alternatives,” the denial letter reads.

Wendy Wright, St-Amour’s nurse practitioner, says the two alternative drugs her insurer are mandating could have a negative interaction with other drugs she already takes. She is refusing to prescribe them, and says only Trilipix is safe for St-Amour’s condition.

A month’s supply of Trilipix costs around $190, while the alternatives cost $54.

Wright says she constantly runs into these battles.

“When I choose a medicine that I think is right for that patient, I do it for a reason. Not because of cost. I do it because it is the best medicine for that patient.”

"When I choose a medicine that I think is right for that patient, I do it for a reason. Not because of cost. I do it because it is the best medicine for that patient."

The industry calls the tactic of trying certain low-cost alternatives first ‘step-therapy’. 

A patient starts with the cheapest drug, and if that doesn’t work, moves up the ‘steps’ to a more expensive one.

But opponents call the practice ‘fail first’. And they’ve introduced legislation that would limit how many times insurers can mandate a drug failure in New Hampshire.

“How many times does a person have to fail?” asks Senator Sharon Carson, the bill’s prime sponsor. “How much pain do they have to go through, or some sort of adverse reaction, in order to get the medication that the doctor wanted them to have in the first place?

Carson’s bill, which sailed through the Senate, doesn’t seek to completely outlaw steps. Instead, it would limit the number of ‘fails’ to one. So if you go through the steps and eventually land on a higher priced drug, an insurer couldn’t, down the line, force you to try that same generic again. The rule would also apply if you switch insurers.

“What this legislation does is try to balance. It balances the needs of the insurance companies, but it also balances the needs of the patients,” says Carson.

Then there are the needs of drug companies. They see the steps more as hurdles to their blockbuster drugs. Pfizer is lobbying for the bill in New Hampshire, and similar legislation is pending in other New England states, suggesting a coordinated effort. A handful of states already have such bans in place.

Insurance carriers, for their part, say steps make sense. In a statement, Anthem writes, “Step-therapy programs are carefully developed using clinical guidelines and have proven effective in decreasing costs without compromising care.”

The concept that doctors start with a cheaper alternative does have traction in the field.

"Doctors and patients both agree that they want the right medicine. But they also want a cost effective medicine."

“Doctors and patients both agree that they want the right medicine,” says Travis Harker, a family physician and current president of the New Hampshire Medical Society. “But they also want a cost effective medicine. They don’t want to go bankrupt each month trying to buy medication that maybe is the same, or has marginal benefit over something that is generic.”

The N.H. Medical Society does support the bill, but Harker says his bigger frustration is the time and resources doctors spend trying to figure out just what an insurer will cover.

Amanda St-Amour and her nurse practitioner have been fighting for coverage of Trilipix for over a month.

“I hope that we are able to get it covered eventually,” says St-Amour. “Maybe if my practitioners keep sending in letters to the insurance company. Because there’s only so much I can do as one person versus the health care industry.”

The proposed step-therapy legislation hasn’t been scheduled for a vote yet in the New Hampshire House.

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