Shalina Chatlani | (TNS) Stateline.org
Cassidy Yermal, 32, began experiencing debilitating migraines when she was 17 years old. As a teenager growing up in northeastern Pennsylvania, she saw numerous neurologists and tried a variety of medications before finding one that provided relief.
In 2022, her new insurer asked her to prove it.
Yermal now lives in Marlboro, Maryland, where she’s a sales representative at a furniture store. She is married and receives health care coverage through her husband’s employer. In 2022, their new insurer told Yermal that it wouldn’t pay for her medication unless she tried several less expensive drugs first — or could prove that she already had.
“I was like, ‘I don’t know why they’re asking for this documentation now. My other insurance company didn’t ask for it,’” Yermal told Stateline. It was “really frustrating to me to have to dig up the kind of things that I knew didn’t work.”
Millions of Americans have experienced similar frustrations under protocols known as step therapy, or fail-first policies. Insurance companies, and the pharmacy benefit management companies that handle prescriptions for them, often refuse to cover a specific drug until after the patient has tried cheaper alternatives. Insurers argue that step therapy — taking drug treatment one step a time — prevents wasteful spending by directing patients to less expensive, but still effective, treatments.
But patient advocacy groups and physicians say doctors, not insurers, are best qualified to know which drug or treatment is likely to be most effective. Delaying the implementation of that decision, they say, often harms patients.
At least 36 states — including Maryland, where Yermal lives — have laws that are supposed to limit insurers’ use of step therapy. But most only apply in certain cases, and enforcement has been spotty. Most important, states do not have the power to regulate the self-funded insurance policies that large employers typically offer to their workers — and 65% of Americans are covered that way.
Only Congress has the power to curb the use of step therapy in self-funded plans; a bill that would do just that is pending on Capitol Hill. In the meantime, legislatures in several states, including Illinois, Kentucky and New Mexico, this year approved measures designed to close loopholes in their step therapy laws and extend protections to more people. The Kentucky and New Mexico bills are now law.
The Illinois measure, which is awaiting the signature of Democratic Gov. JB Pritzker, is especially far-reaching: It would ban any insurers regulated by the state, including Medicaid, from using step therapy. But because states can’t regulate self-funded insurers, many Illinois residents wouldn’t be covered.
“Knowing that our hospitals have hundreds of employees on staff just to deal with the insurance companies really says something,” Democratic state Rep. Anna Moeller, chief sponsor of the bill, told Stateline. “Nobody should be turned away in the middle of a mental health crisis or spend months potentially failing on other drugs while the doctors know they won’t work. No one should have to go through that.”
Illinois Democratic state Sen. Laura Fine, another sponsor …read more
Source:: The Mercury News – Entertainment
