BOSTON (CBS) – Imagine being sick, but being unable to have access to the best medicine to treat your disease. It’s a reality for people all over Massachusetts because of a cost-saving protocol used by many insurance companies. Lawmakers on Beacon Hill are considering a bill to fix the problem, but they are running out of time.
Eitan Kling-Levine, 22, knows this issue all too well. While studying abroad last year, the seemingly healthy college senior was diagnosed with Colitis. By the time he made it back to Boston, his digestive system was in crisis. His doctor prescribed a medication but after one treatment, Eitan got bad news. “We found out that my insurance wouldn’t pay for it. They said that you have to go through two other medications and you have to fail on those two before they will pay,” he explained.
It may sound hard to believe, but it is a common protocol called ‘step therapy’. Insurance companies require patients to try cheaper drugs before the more expensive treatments will be covered. Eitan’s mother Adina was emotional as she described the six month period watching Eitan’s health decline. “He lost over 20 pounds. He was very weak and could barely function,” she said.
Eitan’s insurance company, Blue Cross Blue Shield of Massachusetts, wouldn’t discuss specifics of the case without permission from Eitan to review his files. But in a statement, a company spokesperson said:
Our promise is to always put our members first, and we work hard to ensure our members have access to the highest quality care.
Without having consent from the member or knowing who the member is, we cannot discuss any specifics for this case.
As outlined on our website, Step Therapy is a key part of our prior authorization program for our accounts that have pharmacy coverage through Blue Cross. Some accounts do not acquire their pharmacy benefits through Blue Cross. This process helps us provide members with appropriate and affordable drug treatments. The first step in Step Therapy is to provide members with medications that are clinically effective, affordable generic drugs. The second step is to offer our members more expensive, brand-name drugs. If a member has already tried a first-step medication and their doctor prescribes a second-step medication, coverage for that second-step alternative is automatically approved in most cases. Our full policy on Step Therapy can be found on our website. When making a decision on which treatments we cover, we look at all of the scientific evidence that has been produced.
Our members who have questions about their coverage can find more information on our website or by calling the member services number on their card.
But this is not an isolated incident. Dr. Matthew Hamilton of Brigham and Women’s Hospital told us nearly half of his patients run into this problem. “Patients are teetering on the edge and if they are not on the right medications, they can get very sick, very quickly,” he said.
Eitan will never know if his outcome would have been different if he had been able to take the original medication as is doctor prescribed. By the time he received the full course of that drug, he was very sick. In the end, he needed to have his entire colon removed. “I feel like I am grieving over a year-and-a-half of life that I lost and the body I once knew”, he said.
Lawmakers are considering a bill right now that would make it easier for doctors to ask for exemptions to the step therapy rule to make sure patients get the best medication for their conditions. They have until 5pm on June, 22nd to either report the bill favorably out of committee or it will essentially die for this session.