RICHMOND, Va. — A bill in the General Assembly is trying to create more transparency when your insurance company overrides a doctor’s prescription for another drug or treatment.
“We had no idea how difficult it was going to be,” Tom Eam said. Going through three rounds of chemotherapy, Eam fought lymphoma for 20 years.
“With things looking so bad, it was kind of Tom’s decision whether he wanted to spend with a treatment that wasn’t going to work,” Tom’s wife, Liz Eam, said.
When Eam and his family moved back to his hometown of Williamsburg, his doctor suggested a new treatment.
Before moving forward, the new insurance company wanted proof that the old treatment didn’t work.
“A new drug was an option, but you had to have failed chemo with the former drug, which Tom did, or insurance wouldn’t have paid for it,” L. Eam said.”He had a doctor that went to bat saying this guy’s already tried this and we need to try something new.”
This insurance protocol is called “step therapy” or “fail first” to some. Delegate Glenn Davis (R-District 84) is working on legislation, HB2126, to change the criteria companies use for it.
“It does not eliminate step therapy,” explained Davis. “It creates transparency around the process and embodies some reasonableness in there to make sure that you don’t have to repeat a process with drugs that you’ve already had adverse reactions to or have not worked in the past.”
The bill would allow providers to ask for an exemption for their patients to override step therapy “in favor of immediate coverage of a selected prescription drug.”
Also, if you change providers, under the legislation, you wouldn’t have to repeat the steps to prove a drug doesn’t work. You also wouldn’t get “kicked off a drug that is treating your affliction” if you get new insurance, Davis says.
“We want to be very careful what the process is and when we allow a doctor’s opinion to be overridden by an insurance company,” Del. Davis said.
Some form of this bill has been proposed over the past four years by Davis, after seeing the toll step therapy took on his wife.
“I couldn’t believe this was happening,’ Davis said. “My wife’s doctor could prescribe a treatment that was for a skin disease and that the insurance company that their opinion is more important than her doctor’s opinion that she’s known for years.”
The bills in the past didn’t gain as much traction. Davis says that’s because other lawmakers didn’t know what this insurance protocol was and how it impacts patients.
Officials from the Virginia Association of Health Plans say step therapy is important because sometimes there are treatments available that are more cost-effective options.
“If there’s a generic,” said Doug Gray, executive director of the Virginia Association of Health Plans, “you want to try that first. It’s the best thing for the patient, it’s the best thing for everyone because it avoids unnecessary expense on both ends.”
VAHP officials say healthcare companies also want to make sure new drugs are the right choice for their clients.
“They have to go through trials and tests to make sure they’re safe,” Gray explained.
The Eam’s insurance went with the doctor’s suggestion and now Tom’s cancer is in remission.
“The first time we saw a clean CAT scan we didn’t know what we were looking at because we hadn’t seen one in over 20 years,” Liz said.
They hope other families can become their advocates.