Insurance Barriers

Insurance companies use a number of approaches to cut costs. This can mean your health plan won’t cover certain treatments prescribed by your health care professional or the plan requires you to take a number of steps before your treatment is approved. These practices may violate state or federal laws put into place to protect you. To find out if your insurer may have acted improperly, ask yourself these questions.

Step Therapy

Is my insurer making me try a less expensive treatment before covering the medication that my health care provider prescribed?

This practice is referred to as step therapy. It may violate certain federal and state laws if applied in a discriminatory manner, which means that the insurer treats you and others like you less favorably solely because of your health condition.[1]
Step therapy

Adverse Tiering

Do I have to pay an unaffordable co-pay or co-insurance for most, if not all, drugs that treat my condition?

This practice is referred to as adverse tiering. It involves placing certain drugs, such as those used to treat chronic conditions like cancer, HIV, and rheumatoid arthritis, in more expensive cost-sharing tiers, causing you to pay more out-of-pocket for those drugs.[2] It may also violate certain federal and state laws if applied in a discriminatory manner.
Adverse tiering

Nonmedical Switching

Is my insurer forcing me to take a different medication, even though my current medication works well, by refusing to cover it any longer or increasing my co-pay or co-insurance?

This practice is referred to as nonmedical switching. It occurs when your insurer (not your health care provider or pharmacist) forces you to switch from your current medication to a different (but not generic) drug by either refusing to cover your drug any longer or increasing the out-of-pocket cost of your drug.[3] It can violate certain state consumer protection laws.
Nonmedical switching

Prior Authorization

Is my insurer requiring my health care provider or me to obtain approval before it will cover my medication?

This practice is called prior authorization. It occurs when your insurer requires you or your health care provider to obtain its approval before it will cover a treatment.[4] Prior authorization policies can delay or interrupt care, waste time, and complicate medical decisions. These policies can violate state and federal laws if applied in a certain manner.
Prior authorization

[1] Paul Sisson, Bill Would Quicken Access to Newer Meds, San Diego Union-Tribune (Oct. 3, 2015). http://www.sandiegouniontribune.com/news/2015/01/03/ab374-chronic-disease/.

[2] Chad Brooker, Waging War on Specialty Pharmaceutical Tiering in Pharmacy Benefit Design, 7 Health L. & Pol’y Brief 25, 29 (2012-2014).

[3] Keeping Stable Patients on Their Medications, Coal. Of State Rheumatology Organizations, http://www.csro.info/Switching (last visited Oct. 17, 2016).

[4] Commentary: Time to Reform Costly, Burdensome Prior Authorization and “First Fail” Protocols, Palm Beach Post (Mar. 2, 2014), http://www.palmbeachpost.com/news/news/opinion/commentary-time-to-reform-costly-burdensome-prior-/nd3Zz.