feeling_pressured_dear_addyDear 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?

Feeling Pressured

Dear Pressured,

There is no clear legal answer to your question: is an insurer 鈥減racticing medicine without a license鈥 when it requires you to try (and 鈥渇ail on鈥) one prescription medicine before it will cover the treatment your doctor believes is most appropriate for you.

Here鈥檚 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鈥檚 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鈥檚 own doctor has to prevail 鈥 that individualized decision should not be overridden in favor of some 鈥渙ne size fits all鈥 formula adopted by an insurance company.

For more information, please read HFA鈥檚聽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鈥檚 Project CALLS. Using data from Project CALLS, HFA is advocating for state and federal legislation to put guardrails around insurance companies鈥 use of step therapy protocols and other practices that interfere with access. Together, we can make the case that our own doctors 鈥 and NOT our insurance companies 鈥 should have the ultimate say in determining our treatment.


Have a question? Click HERE. Your name will be changed in the response.

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 鈥淒ear Addy.鈥 Questions submitted to this column are edited in order to protect privacy and should be considered educational only, not individual guidance.


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