Step Therapy – Health Care Cost Effectiveness at What Cost

In an attempt to drive down health care costs, insurance companies are utilizing what is commonly called “Step Therapy”. Step Therapy, also called Step Protocol, forces patients to try the least expensive drug for a particular condition first to see if it is effective. If that drug is not effective, then the insurer will approve payment for the next least expensive drug and so on. From allergy and heartburn medications, to blood pressure medications, to medications for pain, New Jersey doctors and patients continue to be denied and denied again when it comes to Step Therapy.

And while maintaining health care costs is a good thing and cheap generic drugs are typically as effective as their expensive brand name counterparts, is it really fair to deny coverage for a drug that your doctor believes is the most effective drug for the treatment of your medical condition? Apparently, the state of New Jersey believes that the Step Therapy protocol is unfair – because New Jersey regulations prescribe this practice of forcing patients and their doctors to take cheaper medications first – especially when the doctor knows this is not the standard of care. Then, the question is, why are New Jersey insurers violating these regulations and requiring New Jersey patients to try cheaper, potentially less effective medications against their doctor’s wishes? The answer is simple. No one has stood up to these insurers and demanded they stop this questionable, and at least in New Jersey, illegal practice.

Ironically, this practice of challenging a doctor’s prescribing habits may ultimately backfire in controlling costs if patients get ill from taking a less effective drug for their condition. These insurers are gambling with patient health. Doctors are in the best position to determine what particular drug best suits a particular patient and his or her condition. When insurers begin making decisions for doctors, patients lose. And, ultimately, the insurers may lose as well.

If you’ve been injured as a result of an insurer denying coverage for a medication prescribed by your doctor or even if you are paying out-of-pocket for a medication denied by your New Jersey insurer, contact us at Pogust, Braslow & Millrood. We are not afraid to stand up to these insurers.