At the Lupus Foundation of America, we are constantly seeking to improve the lives of people with lupus, including by advocating for policies at both the federal and state level that make it easier for them to access high-quality healthcare and prescription medications.
One of the consistent barriers we hear about from people with lupus is step therapy, which is a tactic used by insurance companies to attempt to lower their costs by pushing patients to cheaper medications instead of the ones prescribed by their physicians.
At its least harmful, step therapy delays people with lupus from accessing the medications prescribed by their doctors – at its most harmful, it can prevent people with lupus from ever being able to access that medication.
Our Advocacy & Government Relations team over the last several years has been advocating for policies at all levels of government that place guardrails around step therapy protocols to ensure people with lupus can access their medications in a timely manner with limited hassle.
Step therapy is a cost-containment strategy used by insurance companies that goes into effect when certain medications are prescribed by a patient's healthcare provider. When a medication is subject to step therapy, the insurance company requires the patient to first try a different medication, chosen by the company. After demonstrating that the medication chosen by the insurance company has failed to successfully treat the patient's condition, the patient will be able to access the medication originally prescribed by their provider – for this reason, step therapy protocols are often referred to as "fail-first."
Unfortunately, many people living with lupus are subject to this “fail-first” protocol when it comes to accessing newer medications that may be more expensive for the insurance company. Insurance companies implement this policy to mitigate costs by requiring patients to try the cheaper drug before “stepping up” to the drug originally prescribed by their doctor.
Olga Lucia Torres is a long-time lupus advocate and the Advocacy Chair for the Foundation's Northeast region. In this video, she describes her experience with step therapy and how it negatively impacted her health.
Many long-time clinicians describe a lupus patient's treatment as a puzzle – with so many varied symptoms that can change from one day to the next, it's vital to the patient's health that their physician is able to quickly amend their treatments without delay. Follow along with the example below to see how a person with lupus may experience step therapy and how it can delay their treatment.
Because of some new lupus symptoms she experienced over the weekend, Maria sees her doctor who recommends she add a new medication to her treatment regimen, Drug A. Her doctor sends the prescription to her pharmacy and later that day. Maria heads to her pharmacy to pick up the new medication. At the counter, the pharmacist tells her that her insurance is refusing to cover Drug A because it's subject to step therapy – before they'll cover it, she'll need to try Drug B.
Maria, still experiencing symptoms and without the new medication, calls her doctor's office. The staff tells her that they'll contact her insurer to request an exception to the step therapy requirement since she has already tried Drug B in the past and it was ineffective.
Maria finally hears back from her doctor who tells her that her insurance company has denied her request for a a step therapy exception. Maria can either appeal the denial, begin taking Drug B, or pay out of pocket for Drug A – Maria elects to file an appeal.
Maria's doctor filed the appeal on Friday, but the insurance company only promises a turnaround time of 3 business days. Finally, Maria hears from her doctor that the insurance company has ruled in her favor and they will begin covering Drug A immediately, Maria picks up the prescription later that day – in total, step therapy has created a delay of 8 days and an extra trip to the pharmacy. Fortunately for Maria, her doctor was knowledgeable about the exceptions process and diligent about filing the necessary paperwork.
In March, the Kentucky General Assembly unanimously passed legislation that updated the state’s existing step therapy law to better serve the interests of Kentuckians, including those with lupus, that rely on prescription medications to effectively manage their health. Learn more about how the legislation and how the Foundation's advocacy helped make it possible!
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