Insurers need transparency, standardization in step therapy

An illustration of an array of prescription medications. (Photo: Adul10, via Shutterstock)

Living with a chronic condition has its challenges. The symptoms can be debilitating from not being able to get up from bed to excruciating pain. Treatment innovations for severe conditions have significantly improved quality of life, but there are continued hurdles to get those treatments.

Due to cost-cutting policies, health insurers often become a barrier to access for medicines that providers prescribe to patients. One such practice is referred to as step therapy.

Step therapy forces patients to try several medications before approving the medication originally prescribed by the doctor. Insurer protocols in treatment delays have shown to cause irreversible deterioration in a patient’s condition and lead to additional, costly medical interventions that could be prevented.

My insurer recommended I take injectables which ended up causing new side effects for me.

This hits close to home for me, as I was diagnosed with Relapsing Remitting Multiple Sclerosis (MS) at 19 years of age. At that time, the medication approved by my insurer caused flushing, burning, rash and redness all over my body. I would also have abdominal pain, diarrhea, nausea, vomiting and indigestion.

My insurer would not cover the medication prescribed by my doctor. I appealed twice and was denied access to the medication both times. Instead, my insurer, under the guidance of an obstetrician and not a specialist in the treatment of MS, recommended I take injectables which ended up causing new side effects for me.

Assemblymember Dr. Joaquin Arambula (D-Fresno) has authored Assembly Bill (AB) 347, which would create a more transparent and standardized process in step therapy protocols. The bill would require health insurers to formulate a standard exception process, require an insurer to send an approval or denial request, and create clinical peer-to-peer review appeals by specialists working in similar medical fields.

It has been seven years since I was first diagnosed with MS, and I am still in the battle for my health to improve. With continuous denials, I have taken the next step — requesting the medication prescribed by my doctor directly from the manufacturer. My case is being reviewed but, in the meantime, I am receiving samples which has improved my condition and without any side effects.

Unfortunately, my experience is not unique.

I am one of thousands of patients who are being denied doctor-prescribed treatments. Some of us are living with symptoms and medication reactions that can be avoidable with new and innovative medicines. Additional guidelines and processes would ensure that patients like me receive treatments without unnecessary and dangerous delays.

As the bill awaits action in the Legislature, I urge legislators in Sacramento to stand with the most vulnerable communities and support AB 347.

Editor’s Note: Chloe Hubbard is a MS patient and lives in the Inland Empire.

Want to see more stories like this? Sign up for The Roundup, the free daily newsletter about California politics from the editors of Capitol Weekly. Stay up to date on the news you need to know.

Sign up below, then look for a confirmation email in your inbox.


Support for Capitol Weekly is Provided by: