BOSTON — Sammantha Dorazio, of Malden, was a high school senior and three-season varsity athlete when she woke up one day with swollen joints. She was diagnosed with a type of rheumatoid arthritis.

It took her four years to get the medication she needed to manage her condition.

“It didn’t take four years because my rheumatology team didn’t know what they were doing, it took four years because the insurance company was calling the shots,” Dorazio said.

Dorazio, who is now 22 and pursuing a nursing degree, with an undergraduate degree in sports medicine, said she had to take numerous medications that did not work for her in order to get insurance coverage for the one that did. She had to give up sports and classes. She suffered awful side effects from drugs that did not work. “I was crying myself to sleep at night, I didn’t know what was happening to my body,” Dorazio said.

Dorazio came to the Statehouse Tuesday to testify in support of a bill, H.1853/S.1235, sponsored by Rep. Jennifer Benson, D-Lunenberg, and Sen. Julian Cyr, D-Truro, that would put in place stricter rules on the use of step therapy, where an insurer requires a patient to try a less expensive or less potent drug before moving onto a more expensive one.

The bill would establish guidelines for step therapy, which insurers say would essentially ban the practice. The therapy would have to be based on clinical prescribing guidelines and medical evidence. An exception would have to be granted for numerous reasons, including if it is deemed in the best medical interest of the patient, or if the patient has tried the other drug previously.

The bill is pitting patient advocates against insurers.

Neil Minkoff, medical director of the Massachusetts Association of Health Plans, said that, in many cases, less expensive generic drugs work just as well for most patients as newer, more expensive ones. Sometimes step therapy is used to encourage a safer alternative to an addictive medication.

“There’s always a continual move to move to the newest, coolest drug, and it’s not necessarily the most effective, and that is driving costs up tremendously,” Minkoff said.

Sarah Chiaramida, vice president of policy for MAHP, said the price of prescription drugs continues to drive health care costs up. “Health plans need the ability to be able to manage the drug benefit to provide members safe access to the drugs they need while keeping costs down,” Chiaramida said.

But doctors and patients say a decision on which medication to use should be up to medical professionals, not insurers.

Dr. Avery LaChance, a dermatologist at Brigham and Women’s Hospital, said she prescribes a specific medication based on the profile of the patient — for example, a patient might have multiple conditions. But sometimes a patient finds a medication that works for them only to have to switch back to a medication that did not work previously because they switched insurance plans.

“With step therapy, the system is really broken,” LaChance said. “We see long wait times for medications, patients not getting access to drugs they need.”

Carlton Zeigler, who works with the Epilepsy Foundation of New England, which supports the bill, said he had seizures and was hospitalized more than once after a pharmacy switched his medication from a brand name drug to a generic drug. Once the switch was at the request of his insurer, another time it was because the pharmacy purchased the cheaper drug.

“This bill would prevent them from forcing me to switch, and it would prevent them from switching me without notifying me and my doctor first,” Zeigler said.

https://www.masslive.com/news/2019/10/bill-limiting-step-therapy-pits-patients-against-insurers.html