Voices Across America

State Regulated Plans Still Subject to Step Therapy

Shar Davis

State: Georgia
Congressional District: GA04


Kidney Disease

Issues and Challenges

Shar Davis has encountered: Access to Medicine, Insurance Issues, Medicare / Medicaid Issues, Prior Authorization, Step-Therapy / Fail First

My Story

As a Caretaker for my aging mother who has multiple health conditions, it surprises me that her care is regulated by insurance companies mandating what she can and cannot take because of formulary status and rebates. With several Medicare Advantage plans or Medicare Replacement plans, step-therapy requirements have been an issue for her physician in making the best clinical decision on what to prescribe her. The insurance companies are taking away the physician’s choice because of the financial impact on the payer.

With this particular illness, Chronic Kidney Disease (CKD), according to her insurance, she had to try and fail a preferred drug first before she could take the drug that her specialists believed she would do well with based on her medical exam and medical history. We attempted to get a prior authorization for the drug that the urologist suggested but the PA was denied based on not medically necessary. We appealed the denial and it was upheld with no exception process. We could’ve taken it further by requesting a peer-to-peer between a Medical Director within the payer and the urologist to provide clinical data for medical necessity but decided not to. We followed the guidance from the payer with their preferred drug but my mother was not responding well to it. She still had excessive fluid around the kidneys and they could not decide as to why this was happening. During this timespan of about six months, she had several ultrasounds, a CAT scan, and finally a Dye Cystoscopy because of the Hydronephrosis.

In the state of Georgia, there is a Step-Therapy Override that requires a step-therapy appeal or exception request to be granted if the plan preferred drug is contraindicated, likely to cause an adverse reaction or physical or mental harm, expected to be ineffective, or not in the patient’s best interest due to medical necessity. However, this did not apply to my mother’s insurance plan because those conditions affect state-regulated commercial plans or state employee plans and not federally operated plans like Medicare or Medicaid. Medicare Advantage plans implemented step-therapy requirements a few years ago which has been a barrier to patients accessing much-needed or life-saving drugs.

My Motivation and Inspiration

What inspires me is helping my family members have access to care and expanding that reach to people in underserved communities where there is limited access and resources.

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