insurance paperwork with a big red NO stamp

What Is "Step Therapy"?: The Impact of Insurance on Our Treatment Decisions

My ulcerative colitis symptoms have mostly been controlled by 5-ASA medications. These medications help manage my symptoms, averting the increased urgency or bloody stool that accompanies flares.

IBD treatment hurdles: should I go on biologics?

However, my UC treatment path hasn't always been smooth. Instances of low iron necessitated infusions, and I've had flares since my diagnosis. I've discussed starting biologics with my provider, yet my symptoms consistently eased, diverting us from that route.

For severe forms of Crohn's disease and ulcerative colitis, starting with a 5-ASA might not align with your medical provider's recommendations. You may need to start on biologic therapies immediately to control symptoms and achieve remission.

But insurance is a hurdle, too

But insurance companies often mandate trying and failing with less expensive drugs before approving costlier biologics. From a patient's standpoint, this delay in appropriate therapy can worsen our conditions before we are finally approved for the original intended treatment.

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Discovering the right treatment involves navigating many loops and hurdles. While advocating with the Crohn's and Colitis Foundation for IBD Day on the Hill, I learned about step therapy reform. Step therapy reform works to avoid fail first protocols and put patients on the therapies their physician originally prescribed them in a timely manner.

The problem with "step therapy" in IBD treatment

I encountered a step therapy issue during a recent flare while I studied for my medical school board exams. The increased stress from studying likely worsened my condition, and my 5-ASA medications were not controlling my symptoms.

After speaking with my gastroenterologist about starting biologics, I underwent a colonoscopy which revealed inflammation located exclusively in the rectum. My doctor initially prescribed an adjunct 5-ASA suppository, which did not resolve my symptoms. Therefore, we increased my suppository dosage, however, my insurance company denied the claim.

The reason we need step therapy reform

Even though my flare symptoms continued without relent, my insurance company stated I did not fail treatment and thus was not approved for an increased dosage of the suppository.

While reading the claim, I dishearteningly realized a gastroenterologist hired by the insurance company – someone who I had never met – reviewed my charts and deemed that I had not failed treatment.

Getting my meds without insurance

Thankfully, my gastroenterologist avoided the insurance hurdle by prescribing my increased dosage of suppositories to I received the prescription at a reasonable, albeit non-insured price, and my symptoms soon resolved.

Because of the localization of my inflammation in an otherwise normal colonoscopy and symptom resolution after suppositories, my gastroenterologist and I agreed to continue on my 5-ASA medications without any escalation in treatment.

Being proactive about IBD flares

Because I believe my flare was induced by a stressful period in life when studying, we developed a work-around solution if I know there is an upcoming stressor in my life, like another exam, to prophylactically start suppositories to prevent a flare from starting.

Ultimately, I may need to go on biologics

I've found stability with 5-ASA medications while navigating the occasional flare, but I do acknowledge that my future may include a step up in treatment regimen. And while transitioning to biologics can feel daunting, I know that treating IBD often requires changes and adjustments.

Despite this treatment stress, I'm grateful for the array of biologic options we have available today – and that the will be there if I end up needing them.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

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