pills spilling out of bottle
Photo Credit: "Spilled pills_1", © 2010 Ano Lobb, Flickr | CC-BY | via Wylio

“Step therapy” is the seemingly innocuous name that insurance companies give to the practice of insisting that patients try and fail treatment on less expensive drugs before moving on to more expensive ones.

A friend writes:

As a parent of two children diagnosed several years ago with ADHD, I have come to find that there is no easy answer in medication as a treatment. BUT IT HELPS, in our case.

The decision to medicate our child essentially for the duration of schooling is a big one, and the medications available have side effects that impact the child and the rest of the family.

In our case, there have been some trial-and-error periods as to which medications work for our children’s symptoms and which ones either don’t work or cause things like challenging mood swings and OCD-like habits. These medications can really mess with their brains, and wreak havoc on the family if they don’t work.

Different kids, different meds

In our case, one child does pretty well with Adderall and the other does better with Focalin. They have shown positive results on them for a few years covered under the same insurance plan with Aetna (through our employer).

In September as we got ready to get back to school, we received a letter for both kids from Aetna that their medication won’t be covered and they would need to try and fail three formularies before the company would consider covering.

One option was to appeal the decision. The two different doctors we use for them had to submit pre-authorizations by phone or email, and they did.

One was authorized to go back to the original medication, and one was denied with direction to continue to try different medications.

Why? One doctor was completely transparent, the other said what was needed to say to game the ridiculous system.

We tried two medications over two months with extreme mood swings and terrible results. Ultimately, I pleaded with my employer to work through the company channels with Aetna to override.

Two months of hell

This worked, and both are back on their medications that work best for them, but it took two months of hell, $200 in co-pays for medications that didn’t work, not to mention the challenges with scripts to drugs considered narcotics that require hand scripts picked up and delivered in 30-day windows. Out-of-pocket costs for both medications if we elected to go around insurance coverage would have been $500/month.

What prompted the medications to be denied after several years of continuous use without question? A summer break of no medication that we didn’t fill prescriptions.

We elect not to medicate our children on weekends, holidays and summer so they can catch up on weight gain and have better appetites than they have while they’re on medicine.

The prescriptions must be filled within 30 days, and we hadn’t needed any for 10 weeks. The gap in filling the prescriptions prompted the insurance company to handle it as a new case vs. a continuous treatment.

If I’ve learned anything from this situation, 1. I should fill medication I don’t need so it won’t be flagged to the insurance company 2. Have a doctor that is willing to navigate the unreasonable elements of the system.

Jeanne Pinder

Jeanne Pinder  is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded...