Step therapy interfered with my bone loss treatment
Congressional District: VA08
Issues and Challenges
Sarah has encountered: Copay Issues, Insurance Issues, Financial Assistance, Step-Therapy / Fail First
I am Sarah and I reside in Alexandria, VA in Congressional District 8.
I have osteopenia, a common chronic condition that began with a loss of my bone mass and my bones getting weaker from a loss of calcium. Because I am postmenopausal and have osteopenia, I am at a higher risk of having osteoporosis. My OB/GYN prescribed an oral bisphosphonate but I was concerned about the side effects.
For several years, I tried to slow my osteopenia with a healthy diet and exercise but those alone were not enough. After my bone mass continued to decrease, I went to see an endocrinologist to discuss my treatment options. We decided I should try Reclast, a type of bisphosphonate treatment that you receive intravenously just once a year. I unfortunately experienced terrible side effects causing me to be extremely wary of taking this medicine ever again.
The following year, my doctor and I agreed I should try a well-tolerated alternative - denosumab (Prolia) which is administered twice a year via a sub-Q injection. I had ZERO side effects with Prolia and now am no longer afraid to receive this medication! But getting it was a big challenge because my insurance company wanted me to keep taking Reclast.
That’s because getting my insurance company to continue covering an already APPROVED therapy was easier for them than getting a NEW one approved.
Rather than standing down and agreeing to take a medication that I knew was not right for me, I decided to advocate for myself and it worked!
I made many phone calls to my insurance company which ultimately resulted in my getting connecting to the medical reviewer for my case.
I explained my situation calmly and professionally and she agreed to see what she could do.
I made sure to get her name and phone number so I could follow up with her directly.
It is so important I advocated for myself and also became directly involved EARLY ON to understand the PRIOR AUTHORIZATION PROCESS in place for Prolia since these types of medications are expensive.
Throughout the process, I made sure to be in regular communication with my doctor’s office so we were all on the same page and they could support me by providing medical documentation to substantiate my case.
Once you take Prolia, you must continue it every 6 months for life. As I prepare for my 2nd injection this year, I will have to go through this process all over again. I just started a new job so my insurance has changed and don’t know yet how the process will unfold with my new insurance plan but as a result of this experience I am more knowledgeable and confident to advocate for myself.
Patients like me need access to educational resources to discuss treatment options with their doctor and tools to help them navigate the insurance coverage process. Providers also must have staff who are knowledgeable about insurance coverage and prior authorization so they can assist patients efficiently to ensure they have access to medications that will improve their health outcomes.
Thank you for listening to my story.
My Motivation and Inspiration
To be in the best health possible for my own well-being, care for my family, and make a difference in society.