Prescription Process

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Formulary Restrictions Non-Medical Switching Prior Authorization Special Tiers Step Therapy Therapeutic Substitution

May 14, 2018 Her only chance at life is a new liver, but her insurer said no. Then she wrote a powerful plea to the CEO All Erika Zak wants to do is play with her daughter on the playground. Take her to the zoo. Walk her to school. She's never been able to be the… Read more

March 2, 2018 ‘Gag Clause’ Keeping Pharmacies From Revealing Lower-Cost Drug Options Obscure rules that cost patients money when they’re buying prescription drugs have been a pharmaceutical industry standard for years, and now a bill in the state Assembly is targeting the practice. Read more

November 28, 2017 Number Of California Patients Fighting Insurance Denials Is Up, Cases Nearly Triple Nancy Fellmeth keeps a 5-inch binder of insurance paperwork in her Northern California living room. Documents about her adult son’s autism treatment poke out from the sides. Some are denial… Read more

May 9, 2017 Empowering patients with the tools to better understand the prescription process Established in 2006, the Alliance for Patient Access (AfPA) is a national network of physicians dedicated to ensuring patient access to approved therapies and appropriate clinical care. To achieve its… Read more

January 22, 2017 Medications that help mentally ill Tennesseans enjoy productive lives are at risk Formulary Restrictions Non-Medical Switching Like anyone with a chronic condition, it can take years for people living with mental illness, from schizophrenia to depression, to find a treatment that works and with minimal side… Read more

January 19, 2017 Who Pays the Price for health Plans’ Soaring Profits? Formulary Restrictions Prior Authorization The combination of high premiums and more stringent access barriers may explain how health plans reduce the net cost of care per patient. Read more

January 12, 2017 New law limits use of step therapy Step Therapy Governor Andrew Cuomo signed a bill, earlier this month, that will limit health-insurance companies’ freedom to impose “step-therapy” protocols on their insured patients. Read more

January 2, 2017 End bait-switch that allows pharmacy benefits to go poof Non-Medical Switching Right now, commercial health insurers are increasingly modifying prescription benefits at any time during the plan-year. In other words, the plan you signed up for during open enrollment — with… Read more

August 16, 2016 New State Law Regulates Health Insurers’ Prescription Drug Policies Late last week Gov. Bruce Rauner signed legislation regulating health insurance protocols that require patients to start treatment with the least expensive version of a medication their doctor prescribed, even if it… Read more

February 14, 2016 Improving access to cancer drugs When it comes to fighting cancer, Michigan patients need to access a wide array of treatment options. Unfortunately, many therapies are currently unavailable to dangerously ill individuals across our state.… Read more

February 9, 2016 Discourage ‘fail first’ treatment We've all heard the old adage, "If at first you don't succeed, try, try again." Sound advice for many situations — but not when you are talking about one's health. Individuals… Read more

February 5, 2016 Leveling the playing field for cancer patients We all have been affected by cancer. Whether you’re like me and have fought it and come out on the other side stronger for it, or you’ve been a caregiver to… Read more

November 23, 2015 Step therapy: A policy out of step with patient needs Step Therapy From newspapers and television news to social media and talk radio, healthcare often dominates the national discussion, particularly the cost of care. Not as frequently mentioned, however, are the barriers… Read more

November 18, 2015 Consumers say insurance company’s plan to save money costs them pain An insurance company's plan to save money could cost consumers pain. The plan is called Step Therapy. First, a doctor prescribes a certain pill. The insurance company may agree to… Read more

October 31, 2015 With mental illness, there’s no time for ‘fail first’ As the state of our nation’s mental health-care system becomes a matter of public debate, it’s important for policymakers and the public to understand what is being done to help… Read more

September 17, 2015 Bill Passed To Undo ‘Step Therapy’ Rule The California Legislature approved a bill (AB 374) last week to allow providers to sidestep the so-called "step therapy" rule, under which health insurers can require some patients to fail one therapy… Read more

July 27, 2015 Step Therapy: Blocking Mental Illness Patients’ Access to Medication Step therapy requires patients to try medications in a certain order, forcing them to try cheaper medications before being able to "step up" to the more expensive prescription drugs. Unfortunately,… Read more

July 21, 2015 Focus on patients, not profits Practicing medicine has changed. While I can't speak for all physicians, I know that most of us decided to dedicate our lives and profession to the good health of those… Read more

July 3, 2015 As Insurers Crack Down On Costs, Patients Push For Changes To Step Therapy As more people gain insurance under the Affordable Care Act, they’ve been running into problems with medications and finding doctors. Now an old practice--one put in place to address the… Read more

June 29, 2015 Rep. Fine and Sen. Morrison: Illinois patients need better access to prescriptions It’s a familiar scenario for many—you get sick, go to the doctor to see what’s wrong, the doctor writes you a prescription and you soon feel better. Your doctor knows… Read more

June 15, 2015 Step Therapy Prolongs Patients’ Misery Would you go to a mechanic to treat your chronic psoriasis, or your favorite barista for a customized treatment program for your chronic illness? This may sound absurd, but a… Read more

June 9, 2015 Commentary: Doctors must not be kept out of treatment decisions Millions of Californians who have health insurance still may not be able to access the crucial medications and treatments they need. In an effort to contain costs, some California health… Read more

June 2, 2015 Patients should get the drugs that work best Balancing great patient care with cost management is perhaps the biggest challenge in today’s health care system. One tool used by government and private insurance plans alike to try to… Read more

June 2, 2015 Mental illness: Treating patients as individuals Close to 1.2 million adults in California live with serious mental illnesses. Each one of these cases is an individual—a parent or sibling or child—and no two people battling the… Read more

June 2, 2015 When fighting cancer in NC means fighting insurers, too Every day, women like me are living life to the fullest, despite the odds. We are going to work. We are caring for our families. And all the while, we… Read more

May 29, 2015 Insurers use ‘Step Therapy’ for drug coverage Doctors and patients from across the state gathered in Albany on Thursday to advocate for a bill that would make it more difficult for health insurance companies to use "step… Read more

May 29, 2015 Patients, medical groups call on Albany to limit ‘fail first’ insurance policies Patient advocates and medical groups on Thursday were at the state Legislative Office Building to support a bill that would curb so-called "step therapy" or "fail first" policies among health insurers. Groups representing… Read more

May 28, 2015 Regulating Step Therapy Practices (VIDEO) Thursday, patient advocates called on legislators to regulate an insurance practice known as step therapy, or fail first. Step therapy requires patients to try less expensive or more established… Read more

May 27, 2015 Bringing balance back to health care in California: Adrin Nazarian Ensuring effective health care for Californians requires that we balance the need for access to effective medical treatment with efforts to keep spending in check. But while cost containment should… Read more

May 22, 2015 When health insurers try to play doctor, California patients suffer Some California health plans may be jeopardizing the health of patients living with a range of chronic conditions. In the name of cost containment, some plans have enacted policies whose… Read more

May 11, 2015 Insurance practice hurts patients This legislative session, patients in Florida saw to their great dismay that measures to roll back "step therapy" practices failed to become law. Under step therapy, a patient must try… Read more

May 11, 2015 New bill could alter path of Step Therapy Some insurance policies require patients to try medications in a specific order. The process is called Step Therapy. But, patients say it doesn't always work. A new bill could help… Read more

May 8, 2015 Letters: Better services needed for people with mental illness There has been a lot of discussion both here and nationwide regarding the need to have better services for people with mental illnesses. There are at least 250,000 people in… Read more

April 17, 2015 Illinois should regulate step therapy treatments Life can transform in an instant when you're diagnosed with a long-term illness. A bill in the Illinois General Assembly would help patients with diseases such as cancer, Alzheimer's or… Read more

April 17, 2015 9-year-old girl travels to Washington D.C. to advocate for lower costs for arthritis medication Sometimes Cadence Weaver's juvenile rheumatoid arthritis keeps the 9-year-old home from school -- the flareups so intense she cannot walk or write. But, the Napoleon girl isn't letting her arthritis… Read more

April 6, 2015 Peggy Symons: Bills Would Ensure Patients Get Meds Florida legislators have the opportunity to address fail-first insurance protocols that prevent patients like me from receiving medication in a timely manner. I know firsthand what it’s like to be… Read more

December 8, 2014 Comprehensive Medication Management: Collaborating for Better Care, Lower Costs Getting patients’ medications right could save $290 million in avoidable medical spending, Terry McInnis, MD explained in a recent Patient Advocacy Leaders Summit webinar. The proposed solution – comprehensive medication management (CMM) – uses “systematic collaboration”… Read more

November 15, 2014 What if you can’t afford to live? Proposed law would limit cost of life-saving drugs Many patients suffering from rare health problems face high treatment costs. The Illinois Coalition for Access to Affordable Medication, along with some Illinois lawmakers, has crafted proposed laws that would… Read more

November 6, 2014 Medication Restrictions Significantly Affect Mental Health Treatment Outcomes A new study finds many common insurance and state Medicaid policies may negatively impact patient health and impose a major workload on psychiatrists. More than half of psychiatrists surveyed pointed… Read more

November 2, 2014 Crystal Lake resident hopes to ‘cap the copay’ on high-price specialty drugs An Illinois state Senate proposal is attempting to limit out-of-pocket costs for specialty drugs, and a House proposal aims to limit out-of-pocket costs for such drugs. Many states have adopted… Read more

October 11, 2014 Health plans are shifting specialty Rx costs to you Insurers often place specialty drugs in the highest tiers of patient cost-sharing, making it difficult for patients with debilitating conditions to afford treatment. The increasing use of such drug tiers… Read more

October 10, 2014 Exchange plans are failing America’s most vulnerable The Affordable Care Act has helped millions of Americans access health insurance, but there is concern over the quality of coverage. Even with federal subsidies, many available plans make paying… Read more

October 6, 2014 Why extremely expensive drugs are often worth the cost As the rising cost of prescription medicines becomes more widely debated, more attention is being focused on the value proposition. A recent comparison of 58 specialty medicines showed, although specialty… Read more

October 6, 2014 New Insurance Exchanges Fail to Protect Colon Cancer Patients Most formularies have four or more tiers of coverage that place increasing cost-sharing obligations on patients. The highest tier typically involves co-insurance, in which the patient is responsible for a… Read more

September 5, 2014 Fine tune ACA to better aid those with chronic illness New enrollees to the health care marketplace with chronic illnesses are facing barriers to care including limited benefits, high cost-sharing and lack of transparency in enrollment choices. Some plans have… Read more

August 29, 2014 Oral chemotherapy shouldn’t cost more As of 2014, half of all FDA approved oncological medications are oral medications, which are often more effective and sometimes the only available treatment for patients. In Pennsylvania, insurance plans… Read more

August 27, 2014 Insurance issue hurts cancer patients There is a noticeable financial burden placed on cancer patients in Pennsylvania due to an insurance provision that considers oral chemotherapy pills a pharmacy benefit. This requires the patient to… Read more

August 15, 2014 Contention continues on prior authorization, co-pays, co-insurance Health insurance complications such as prior authorization, co-insurance and multiple co-payments predate and are not mandated by the Affordable Care Act. However, changes brought by the new law are contributing… Read more

August 8, 2014 Let’s cut red tape to help patients Prior Authorization Prior authorization, a process where patients must wait until an insurance company approves the use of a medication recommended by their physician, is a critical issue affecting communities and families… Read more

August 6, 2014 AIDS patients fear discrimination in ACA exchange Formulary Restrictions Advocacy groups claim insurance companies are discouraging HIV and AIDS patients by requiring them to pay a percentage of costly medications instead of a flat co-pay, pricing the medications out… Read more

August 5, 2014 MPBN: New law to increase access to chemotherapy pills Formulary Restrictions Non-Medical Switching Prior Authorization Special Tiers Step Therapy Therapeutic Substitution A new law in Maine requires insurance companies who already cover IV chemotherapy to cover chemo pills at the same level by the first of next year, eliminating a barrier… Read more

August 5, 2014 Prior authorization: Valuable cost-saver or bureaucratic black hole? Non-Medical Switching Insurance companies require prior authorization as a cost-saving measure, but the current system doesn't benefit patients or providers. Dr. Danielle Ofri says that, in theory, this is a reasonable way… Read more

August 3, 2014 Adventures in ‘Prior Authorization’ Special Tiers Prior authorization requests consume about 20 hours a week per medical practice and could cost individual practices tens of thousands of dollars a year. Physicians say the time and money… Read more