Did you know insurance companies can change your medication? Here’s why

Editor’s Note: The following is part of a class project originally initiated in the classroom of Ball State University professor Adam Kuban in fall 2021. Kuban continued the project this spring semester, challenging his students to find sustainability efforts in the Muncie area and pitch their ideas to Deanna Watson, editor of The Star Press, Journal & Courier and Pal-Item. Several such stories are being featured this spring.

MUNCIE, Ind. — Doctors diagnosed McKenna Bowes with Lupus in 2019 after months of experiencing various concerning symptoms from a drooping eyelid to fevers to indescribable joint pain.

Once an active cross-country athlete, she wasn’t prepared to be catapulted into the world of life-long medications and constant infusions.

According to Lupus Foundation of America, “Lupus is a chronic, long-term autoimmune disease, which means that [the] immune system — the body system that usually fights infections — attacks healthy tissue instead.” When the Lupus began to attack her lungs, the doctors prescribed an infusion medication called Rituximab, and she received multiple infusions with consistent supervision.

Over a year into her treatment, her doctor called with concerning news: Bowes’ insurance company would no longer pay for the costly Rituximab and required her infusions be switched to a cheaper alternative called Truxima.

What Bowes experienced is called step therapy.

Step-therapy insurance practices can require providers to prescribe a cheaper or more cost-effective medication or treatment before allowing the patient to be prescribed the more expensive version, according to the National Organization for Rare Disorders.

Step therapy often affects patients with more chronic, life-long conditions. Finding medications with cheaper, more generic versions saves the insurance provider more money over time, according to a 2018 study from Case Western Reserve University. Both Medicare Advantage, employee-sponsored insurance and private health plans can have policies that put patients into the step-therapy process.

“I was kind of nervous because just how cautious they are with the allergic reaction [procedures] to the Rituximab,” Bowes said. “The Rituximab [was] working really well, so I was kind of scared for how the new medication was going to treat me.”

Even with prescribing generic versions, “switching from a brand name to a generic of the same drug can have adverse consequences because of lower efficacy of the generic drug [or] allergic reactions,” according to the Case Western Reserve University study. Additionally, the Food and Drug Administration acknowledges “a generic drug may have certain minor differences from the brand-name product such as different inactive ingredients.”

Step therapy is a type of prior authorization, meaning “the [insurance company] reviews the pharmacy health plan benefit to determine whether to approve coverage of a certain drug or therapy prescribed by a [medical] provider. Insurance providers use prior authorization to ensure that [the patient’s] medical necessity for a drug or treatment exists,” according to a study conducted by Xcenda.

The insurance provider can approve or deny a medical provider’s request for a drug or therapy.

“The step therapy is one of many forms of cost sharing or other rules that insurers put in place to be able to monitor or control how much is spent by the [insurance] plan because they can’t tell exactly what is the right treatment for every single person,” said Seth Freedman, associate professor at Indiana University in the O’Neill School of Public and Environmental Affairs.

According to a 2018 study by researchers at Tufts Medical Center: “Health plans tend to more often restrict coverage of drugs indicated for diseases with multiple alternatives. This may be because plans consider drugs in the same therapeutic class to be equally effective and prioritize patients’ access to one or two of those drugs.”  

That’s what happened to Brooke Burnfield.

Doctors diagnosed Burnfield with ulcerative colitis, needing infusions of her medication called Remicade in four-week phases. Even with her provider advocating for her, Burnfield said her insurance company would often deny her the ability to move up or increase her infusions and eventually refused to pay for it. They instead switched her medication to Avsola, which is a biosimilar, or a drug that has a similar formula to the original manufactured drug.

“I was sick for a very long time,” Burnfield said. “I was at a pretty particular low point in my health — just have [my insurance company] be like ‘Oh well, it’s cheaper. What can you do?’ That was just really frustrating.”

Burnfield used her original medication for over two years before her insurance company chose to switch it.

Non-medical switching, or “when a patient is forced to change to a different medication for a non-medical reason,” generally happens because the insurance provider will no longer pay for the medication. It can lead to “disease progression, adverse side effects to new medications, increased medication costs and nonadherence to medication protocols,” according to the Connecticut General Assembly research report.

“The potential benefit of step therapy is the cost savings. Maybe it will make the patient no worse off in many cases. But in other cases, the patient is spending more time waiting for the treatment that can truly help them,” said Freedman.

One of Freedman’s colleagues agreed.

“Insurance can be extremely problematic to navigate, particularly if you don’t fit that mold of what’s expected in the course of one’s treatment,” said Antionette Smith Epps, associate professor at Indiana University Indianapolis Fairbanks School of Public Health and director of Masters of Public Health Administration program. “What you find is research gives us what things tend to do, but it is not predictive of every situation.”

Indiana has an appeal process for patients who believe they do not “fit that mold” and want out of the step-therapy process. Using the Indiana Department of Insurance website, patients can file an insurance company complaint and must receive a response in 20 business days.

Even with some protections, the Indiana Department of Insurance says, “States are not permitted to regulate most valid self-funded plans authorized by Congress under the terms of the Employee Retirement Income Security Act (ERISA).”

According to a 2021 study published by the Cambridge University Press, there are seven primary reasons patients ask for step-therapy exemptions; Indiana allows exemptions for four. The step-therapy laws in Indiana only protect 20% of the insured population that the state law would apply to.

The power that insurance companies have over long-term medical decisions makes Bowes anxious.

“This is a lifelong disease, so things can change. My other two medications have been working so well. Those [medications] I feel like I absolutely need,” said Bowes. “The day that would become a problem would definitely be very scary. It’s always in the back of my head.”