Tag Archives: step therapy

Healthcare in New Jersey – Fail First

The state of New Jersey still allows healthcare providers to override orders from doctors. Despite lacking a medical degree, insurance companies can dictate to doctors what medications to use on patients first. The insurance companies actually have lists of medications for certain medical conditions (which for some reason usually are chronic pain conditions). These lists are generated based on profits and losses. They are based on financial reasons. They are based on closed-door deals the insurance companies have with different pharmaceutical companies. The one thing that is NEVER take into consideration when generating these lists is what is best for the the individual patients.

You might be thinking what’s the big deal. So a patient tries one or two medications first. Maybe those will work; maybe they won’t. However, think about the current healthcare insurance environment. People are shopping around for the best deals. That means people can be switching plans and companies on a yearly basis. Patients would have to prove EVERY TIME THEY CHANGE PLANS that they have already tried their new healthcare insurance’s approved medications and failed to receive relief from them. We all know the red tape and bureaucracy that exist in large companies. It can take weeks or months to finally get approval to fill a prescription that the patient has had for years. If it is a medication taken daily, the risk of withdrawal is not only a potential side effect of Step Therapy ( also known as Fail First), it is a given. Who will care for a patient going threw withdrawal? The Emergency Rooms. It is far more expensive to go to an Emergency Room that to simply be allowed to take a medication the doctor has been prescribing for months or years.

The other problem with this system is that it supersedes the doctor’s medical opinion with the healthcare company’s financial opinion. The doctor supposedly has years of training and continuing education to back up his or her recommendations. What does the insurance company have? A handshake and price cut from their preferred supplier.

There is currently a bill winding its way through the New Jersey Legislature. It was introduced on June 18th, 2012. Where is it now? It is lounging out with the Senate Budget and Appropriations Committee. It has not even been mentioned since January 6th of this year. How long does it take to provide needed relief to thousands of New Jersey citizens?

I challenge the elected officials of New Jersey to dare to do something great.

Step Therapy – All Cons

It has been four weeks since I swallowed my last pill of Relpax – a triptan medication that works great at knocking out my moderate to severe migraines. I tolerate it well with few side effects. I have so many symptoms with my migraines that it is hard to tell if this medication causes any side effects. It is my most reliable medication for migraines. Sometimes, I am able to treat my migraines with over-the-counter meds targeted for headaches. But the Relpax is my safety net. However, the severe migraines need something stronger like DHE (dihydroergotamine). It is a painful medication that causes a shitload of side effects. Firstly, it needs to be injected into my thigh or stomach. Secondly, it burns like acid. It hurts so much I often have to give myself a pep talk before injecting myself with the poison, because that is what it is – a poison. The side effects are numerous and I need to take other medications with it to counter the more severe one (like nausea and vomiting). I avoid taking this med. I hate it but at least it works 99% of the time. It also keeps me out of the Emergency Room. Before I was prescribed this medication, I would go to the ER so often that I should have gotten frequent flyer miles.

It has been four weeks since I ran out of Relpax and I am not down to one dose of DHE left in my medicine cabinet. Thanks to Step Therapy (a.k.a., fail-first therapy), I have to prove to the insurance company that I have tried their recommended triptan medications first before they will pay for my lifesaving Relpax. I have been there, done that, and have the t-shirt to prove it. Unfortunately, my insurance company has changed every year since going on Medicare three years ago. That means that every spring I have to play the insurance company’s game which often delays receiving my medication for two or more weeks.

It has been four weeks since my Relpax was used up. I am saving my DHE for the God-awful, kill-me-now migraines that I occasionally get. I am too scared to take it because I will be left with few choices when it is gone. I have left numerous voicemail messages at my doctor’s office, my pharmacy has faxed over numerous requests and still I have not received prior authorization yet. The only meds I have are either the worthless OTC drugs or the my last-ditch medication that literally puts me in a coma for two days. My husband insists that someone be home to keep an eye on me during these two days because I have hurt myself in the past by falling down. This is not a situation anyone should be in.

It has been four weeks and I do not know why it is taking so long. What I do know is that there has been a bill introduced in my state legislature that would eliminate this offensive hurdle I must jump every year. The bill has been languishing for over a year now. I cannot even express the joy the passing of this bill would give me.

It has been four weeks and I am scared. I am scared of getting a monster headache that won’t go away, that will entrench itself and require going to the hospital. I once had a migraine for two years. That scares me…