Health insurance hurdles—and how to clear them

By Mariah Leach

When I was diagnosed with an autoimmune disease, my doctor explained it could take some time to find a successful treatment. But I didn’t understand how much of the process would involve navigating my health insurance. While issues vary depending on the treatment and type of insurance, here are four of the most common health insurance hurdles and experts’ advice for overcoming them.

Specialty-tier medications

For prescription medications, insurance providers typically have several categories to determine the price patients pay at the pharmacy. They are, from least expensive to most: generic drugs; preferred brand drugs; non-preferred brand drugs; and specialty-tier medications. Unfortunately, the newer, more-advanced medications needed to treat autoimmune diseases often fall into the most expensive category. 

Prior authorization

Before insurance providers will cover specialty-tier medications, prior authorization is usually required. This complicated paperwork routinely causes lengthy delays in treatment, with insurers sometimes taking up to 30 days to approve a request.

Step therapy (“fail first”)

Some insurance providers require patients to go through a process called step therapy or “fail first.” Before the medication prescribed by the doctor will be covered, the patient is required to “fail” on a medication preferred by (and usually cheaper for) the insurance provider. 

Sometimes the substituted medication is equally effective, but the required sequence of medications does not take into account a patient’s medical profile or their doctor’s recommendations. Step therapy often causes patients to live indefinitely without a successful treatment and can end up costing more in the long run because of inefficacy, side effects, or complications.

Non-medical switching

Even when a specific medication is covered and a patient is stable, an insurance provider seeking to control costs might decide to switch the patient to a different medication. Non-medical switching ignores the lengthy process patients and doctors endure to identify successful treatments. It also disregards potential negative impacts such as re-emerging symptoms, undesirable side effects from the new medication, or lost efficacy even if the patient is returned to the original medication.

How to move forward

I know how discouraging these hurdles are. I’ve faced enormous pharmacy bills and made endless phone calls to follow up on prior authorizations. I experienced step therapy firsthand when my insurance provider required me to fail a medication of their choice before covering the one my doctor and I selected to be compatible with pregnancy. 

Here’s what the experts say about how to move forward.

Choose your insurance plan and treatment wisely 

Cindy Steinberg, national director of policy and advocacy for the U.S. Pain Foundation, emphasizes the importance of understanding your insurance options. “I recommend careful research when selecting plans to see what you will be charged for your specific medicines,” Steinberg advises. 

If possible, she also recommends taking cost into consideration when you and your doctor make treatment decisions.

Copay assistance programs

If you’re prescribed a specialty-tier medication, look for a copay assistance program. Though I have experienced some red tape while utilizing these programs, they have allowed me to access life-changing medications I would not have been able to afford otherwise.

Appeal your insurance provider’s decision 

If your insurance provider rejects your claim, ask your doctor to appeal the decision. “I would find the person in your doctor’s practice who handles insurance appeals and get to know that individual,” Steinberg advises.

Steven Schultz, director of state legislative affairs for the Arthritis Foundation, also encourages appealing through an external review process. “Even if you have insurance that is not state-regulated, your state Department of Insurance should be able to assist you with crucial information,” Schultz says.

Reach out to HR

If you get insurance through your employer and are comfortable doing so, Schultz also suggests speaking with your human resources (HR) department. “Educating your HR department on things to look out for as they decide on insurance options for the company is extremely important,” Schultz notes.

In some cases, employers can also work with the insurer to make special exceptions for coverage.

Share your story

“Contact your legislators,” recommends Sara Froelich, executive director of the Chronic Care Collaborative. “You don’t need to be a policy expert; you are an expert on your story and your experience, which is what elected officials need to hear.”

Steinberg adds, “Most public and private payers receive their accreditation through the state. This is where patient advocacy can make a critical difference, and where patients’ voices can help improve access.”

“Patient stories can help drive changes in public policy,” Schultz agrees.

I testified about my experiences with step therapy in front of Colorado state legislators, which contributed to the passage of a bill to protect patients from having to repeat step therapy if they have to change insurance plans.

If you want to share your story but aren’t sure where to begin, reach out to a patient advocacy organization. “The U.S. Pain Foundation offers advocacy training programs to help you get started,” Steinberg explains. 

Whatever health insurance hurdles you are facing, don’t give up. “Don’t take no for an answer,” Froelich stresses.

“We have seen so many success stories of patients getting through hurdles due to amazing persistence,” Schultz agrees.

The only way to change the way health insurance functions is for us to speak up.    •