Dear Addy,
My insurance company is trying to make me go through step therapy to get access to the treatment product I need! Are they practicing medicine without a license and is it illegal?
Sincerely,
Feeling Pressured
Dear Pressured,
There is no clear legal answer to your question: is an insurer “practicing medicine without a license” when it requires you to try (and “fail on”) one prescription medicine before it will cover the treatment your doctor believes is most appropriate for you.
Here’s what we do know:
- First, insurance companies all employ medical directors. Insurance company medical directors are licensed doctors with authority to weigh in on matters such as medical protocol development, covered courses of treatment, network credentialing, etc.
- Second, insurance companies also have Pharmacy & Therapeutic (P&T) committees that evaluate and design their formularies (lists of preferred and non-preferred drugs). P&T committees are made up of pharmacists and physicians. Here, too, licensed medical professionals serve as decision-makers when developing the formularies for the health plans. Most importantly, even though licensed medical professionals are involved in the development of insurance company formularies and step therapy protocols, HFA has consistently argued that a consumer’s OWN doctor is the appropriate medical professional to make prescribing decisions. Prescribing clotting factor is a complex exercise that has to be left to hemophilia specialists in close consultation with their patients. In bleeding disorders care, a strong doctor-patient relationship is essential and must be preserved. The judgment of the patient’s own doctor has to prevail – that individualized decision should not be overridden in favor of some “one size fits all” formula adopted by an insurance company.
For more information, please read HFA’s Step Therapy Issue Brief. Also, if you are experiencing any issues accessing your medicine because of your insurer, please consider submitting your story to HFA’s Project CALLS. Using data from Project CALLS, HFA is advocating for state and federal legislation to put guardrails around insurance companies’ use of step therapy protocols and other practices that interfere with access. Together, we can make the case that our own doctors – and NOT our insurance companies – should have the ultimate say in determining our treatment.
Sincerely,
Addy
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HFA frequently receives questions from the bleeding disorders community related to advocacy issues. The questions often impact the entire community. In an effort to reach the largest audience possible with our responses to these widely applicable questions, HFA developed “Dear Addy.” Questions submitted to this column are edited in order to protect privacy and should be considered educational only, not individual guidance.
