Woman finds out hard away about step therapy

Posted: Updated:

PHOENIX - A Valley woman was shocked when she found out her medication was denied by her insurance, a medication she'd been taking for some time.

Video

What you need to know about step therapy - azfamily.com's Carey Pena's latest 3 On Your Side report about a woman who learned the hard way about step therapy.

>
Search Video:

It was medication her doctor prescribed for severe nerve pain, but her insurance company wanted her to try another medication first. It's a process called step therapy.

"I have nerve damage pain in the feet and hands shaking similar to what ms patients go through," Julie Koehler said.

Koehler takes 19 medications a day

"It's devastating, it's just devastating," she said. "I have to have these medications, some of them I've been taking for 12-15 years."

One of those medications is Cimbalta. Her doctor prescribed for her nerve pain.

It's something she has taken before and that's why Julie said she was shocked when recently she went to fill the prescription and they told her it wasn't covered. It would cost her $303 to fill.

"Went home called insurance company and they said this requires step therapy, what is step therapy?" she asked.

"What it is is a fail first approach we want the patient to try this drug b/c it's cheaper and if they fail on that they try this drug or that drug," Dolinar said.

Dr. Richard Dolinar is an outspoken critic of step therapy; he calls it a form of rationing.

"Insurance companies would push back at you and say costs are out of control they can't afford to go right to the high level high priced medication, the most expensive disease is the one that is not being treated adequately," Dr. Dolinar said.

Koehler just wanted the medication her doctor prescribed; she didn't want to try several others before getting that Cimbalta.

Step therapy, in some cases, Health Choice requires a member to try certain drugs to treat a medical condition before covering another drug for that condition. For example, if drug a and drug b both treat the medical condition, Health Choice may not cover drug b unless you try drug a first. If drug a does not work for you, Health Choice will then cover drug b. Please refer to the health choice formulary to find out if a drug has additional requirements or limits.

But her insurance company, Health Choice, does clearly state that "in some cases (they) require a member to try certain drugs to treat a medical condition before covering another drug."

Koehler appealed her case and called 3 On Your Side for help. In the end, Health Choice agreed to pay the $303 for the medication she needs to control her pain.

What Koehler learned from all of this is that had she known about step therapy, she could have worked this out with her doctor in advance, so that she wouldn't have to jump through hoops when it came time to fill that prescription.

One of the things that helped Koehler make her case to the insurance company was the good records she's kept. She was able to show that she had taken other medications along the way but they did not work to treat her nerve pain.

For more information on how you can be a better advocate for yourself and your healthcare check out the links below.

Resources:

-Contact or .

-More information at Arizona Department of Insurance or call 602-364-2499. You can also go to .