Illinois Tackles Step Therapy / Pre-Authorizations

Efforts are underway in Illinois to pass a bill termed Healthcare Protection Act (HPA) that tackles two insidious problems faced by consumers. Step Therapy refers to process whereby your doctor prescribes a treatment involving X units of BrandNameDrugX and your insurance company rejects that prescription and instead says you need to FIRST try X units of CheaperGenericA, then X units of CheaperGenericB then maybe x/2 units of CheaperGenericC before they will allow a prescription of BrandNameDrugX.

If you’re paying attention, that looks an awful lot like what would result when an MBA and twenty software developers get together to write a program to practice medicine. What that MBA and those coders may not understand is that not all generics are medically identical to their brand name inspiration. But, but, but… How can that be? A generic may have the same active ingredients in the same proportions as the brand name drug but unless it’s made in the same plant(s) via the same processes as the brand name, the generic drug’s chemical behavior can vary based upon the binders used to make it into pill form which can vary absorption rates, etc. which have a big impact on the drug’s effectiveness, especially those requiring a steady delivery over 12-24 hours.

And these step therapy processes don’t limit themselves to only requiring an “exact” generic swap for a brand name drug. Insurers often require trial of multiple “similar” drugs – similar according to the insurer’s view of the world. Again, the problem is that “similar” drugs can have WILDLY different effects on individual patients. Anti-depressant Y may work perfectly for patient A but have no effect on patient B who needs anti-depressant Z.

These per-patient variations in efficacy are not reflected in these software driven algorithms for saving the insurer money. When a person’s blood sugar levels or depression symptoms are on the line, having this external process focused solely on saving the insurer money interfere with the decision of a doctor actually legally responsible for the care of the patient sitting in front of them should be illegal. It’s not practically practicing medicine without a license. It IS practicing medicine without a license.

The proposed HPA legislation also applies limits to “pre-authorization” requirements for some mental healthcare treatments and requires insurance plans to document in writing all procedures requiring pre-authorization so consumers can review those requirements and factor them into their yearly decision when renewing healthcare coverage.

These make perfect sense and can eliminate many of the delays and gotchas that become an obstacle to needed care, especially for the elderly who don’t have the focus to stick to their guns and make all of the calls and wait on hold for 30 minutes per call to fight these bogus rejections and get the insurer to actually pay for the services they claimed to provide.



I didn’t think insurance companies were certified to practice medicine.

The Captain


Sounds like you’re not a fan of generic drugs. Do you know of research on the efficacy of them?


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Sometimes well-meaning politicians cause unwanted side effects. If BrandNameDrug is very expensive and GenericDrugA B or C are reasonably effective, the insurers may simply say “we don’t cover BrandNameDrug anymore”, we cover the generics only. If you want/need brand name, you have to pay for it yourself. That would also avoid this whole rigamarole of approvals, trials, etc. Obviously not to most people’s liking, but it is a solution too.

According to some here in Shiny-land, the choice is between the warm embrace of the insurance companies, or “big gummit death panels”.

No wonder people are so confused.


Send the insurance companies to the “big gummit death panels”. Problem solved.

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I only take four prescription medications and they are all generics. I’m not “for” or “against” any medicine. I’m against having accountants practice medicine and overriding the work of a licensed physician who saw the patient and knows their history. Generics might be 98% as effective as brand names in 92% of the population but if a PATIENT has a history of unique metabolism of some drugs (where they are far MORE effective or far LESS effective), the patient shouldn’t be forced to “try” a cheaper drug for 3-4 weeks before moving up to more expensive alternates as dictated by an insurance company.



Life is much more nuanced than go/no-go or true/false, but often you get lured into a multiple choice reply. Well done avoiding this trap.

The Captain

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