The health insurance industry has a term for this sadistic practice. It's called "step therapy." If the choice is between a more expensive medication that works and a cheaper one that doesn't work as well and might have worse side effects, the insurance company requires that the cheaper drug be used first.
One benefit to the insurance company is that the patient on the cheaper drug might die before they get a chance to use the drug that works but is more expensive. That's money in the bank for the insurance company.
Or, the patient might be so worn down and harmed by the cheaper drug that they just give up the fight to get the drug that will help them. Again, that's bank for the insurance company.
Can't even describe how many times the latter has occurred to me. It's fucking exhausting.
You CAN get exceptions sometimes but the insurance company can just...decide to change their mind, or not honor it, randomly. Or force you to renew it.
My BF gets monthly harassing letters from United pressuring him to go on a medication that doesn't fucking exist. "Friendly" of course, very "Oh heyyy bestie, we're your cute little gatekeepers, tee hee, and we noticed you were on this dumb little druuuug, so icky and expensive. But how about this other one, the generic? Yeah. It hasn't actually been made available yet or anything, this has been an issue for moooonths but it'd be great if you could swiiiitch. We just enjoy making sure you make the best decisions and would love it if you just, like, became unable to hold the job that gets you insured with uuuuuus." *Intense vocal fry*
Good news for people in Illinois, step therapy will be banned starting Jan. 1, 2025! And prior auth for mental health crisis inpatient stays, and junk insurance. It’s the first state to ban step therapy, and won’t be the last (I hope).
lllinois Gov. J.B. Pritzker has signed into law measures to block insurance companies from shortchanging consumers on their medical needs.
And in 2026 will require insurance to cover a name brand medication if the generic is experiencing a shortage.
SPRINGFIELD – Relief from drug shortages is coming soon for Illinoisans with prescription medications, thanks to a new law championed by Sta
And a lot of other cool stuff. So, go Illinois!
If you're facing step therapy rejections for needed medication, tell your provider about steptherapy.com, which is an organization connected to the National Psoriasis Foundation, one of the conditions that deals a lot with this. They provide state by state breakdowns of protections against step therapy requirements that don't help you or don't make logical sense. They also provide forms tailored to each state's specific protective law if one exists and give your provider a straightforward way to state why you need a therapy over its bullshit alternatives. It's concise, to the point and very strongly worded.
I use this at work daily and it's improving our hit rate in fighting step therapy requirements for diseases where a failed step in step therapy means permanent, degenerative harm to their body (not even including mental anguish from having to go through a failed therapy to receive necessary care). If you're faced with shit like this, advocate for yourself as much as you can and go down swinging in the appeals process (every insurance in the US is required to provide an appeals process for denials, you CAN win in there with your doctor's help) if you gotta.
