Regina’s Stand Against Step Therapy
Finding the right treatment for chronic disease can take years of suffering through symptoms. When patients and their doctors do find the treatment that works, the worst thing that can happen is losing access and being back at square one.
After three stable, healthful years using Rituxan to manage lupus and multiple sclerosis (MS), Regina received a call from her doctor that many people living with chronic disease fear. Her insurance company denied authorization for her upcoming Rituxan treatment.
Reaching out for help
Why after such a long time would her insurance company make this sudden decision? Regina’s doctor did not want her to switch medications either. Understandably puzzled, scared, and upset, Regina took her questions to her online group for advice.
“Hey ya’ll… I am so frustrated. My insurance is refusing to pay for my meds. They want me to try the generic Ruxience. I have been taking Rituxan for three years. Anybody on this med? Help!”
Reaching out for support, Regina was one step closer to finding answers when she was put in contact with the Infusion Access Foundation (IAF) team.
Learning about step-therapy
Regina learned she was experiencing something called step-therapy (aka, non-medical switching). Basically, her insurance company was now requiring that she try and fail at a biosimilar drug before granting her access to Rituxan.
Step-therapy is widespread and has nothing to do with doctor recommendations or other health-related reasons. Rather, it has to do with cost—biosimilars tend to be less expensive or have bigger rebates for insurers.
Appealing for patient protections
After working with IAF and her doctor, Regina was able to draft a letter for her insurance company. This letter included information and specific language about patient protections under Ohio’s step-therapy law.
Ohio law requires insurance companies to comply with the Food and Drug Administration (FDA) Purple Book. As it turns out, the Purple Book clearly states that biosimilars, which are highly similar products — but not generics — require prescriber authorization to change.
Since Regina’s insurer did not have prescriber authorization for the switch, Regina had strong grounds for a winning appeal.
The best call
Two weeks later, the IAF team received an update from Regina: Her insurance company reversed their denial, granting Regina access to her medication! With excitement, Regina proclaimed, “My doctor said my letter was the only reason I got my medicine!”
It was Regina’s strength and determination to find the resources she needed to advocate for herself and her health that inspires others today. And the best news, she can go back on the drug that keeps her healthy so she can keep up with her busy life as a recent masters graduate and busy mom.
What does Regina hope others will learn from her experience?
“Consistency is key, and fight like your life depends on it!”
Helping yourself and others
If you or someone you know is facing step-therapy challenges, IAF may be able to help. You can download a letter template similar to Regina’s, sign on to various petitions, and even be a part of talks with lawmakers.
We are here to help you stay on the treatment that keeps you healthy!