ATLANTA — 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 only pay for a cheaper pill. The patient then cannot get the drugs originally prescribed unless the cheaper drug proves ineffective.
A doctor told Channel 2 consumer investigator Jim Strickland the policy is just wrong.
Gary Wright, 49, is diabetic. He suffers from a chronic nerve pain called neuropathy.
"Sometimes when I walk it's like walking on a bed of nails," Wright said.
Endocrinologist Jonathan Ownby gave Wright samples of the drug Lyrica. It's approved by the Food and Drug Administration to treat diabetic neuropathy.
"He started the medicine and his pain went away," Ownby said.
Until his insurance company, Humana, stepped in.
"His insurer told me Lyrica runs $472 a month," Ownby told Strickland.
Wright's insurer opted for a mix of generic medicines. Gabapentin is approved for shingles. Amitriptyline is an anti-depressant. They are not FDA approved to treat diabetic neuropathy. But they are a third of the price of Lyrica.
Wright has already tried the combination treatment.
"The Gabapentin, I've been on it for quite some time. It does not work," Wright said.
It's the same story for diabetic Lindsay Allen.
"I've tried the solution (the insurance company) suggested. It did not work," Allen stated.
Allen got denied three times. Like Wright, he also has his insurance through Humana.
According to the Kaiser Family Foundation, Humana is Georgia's second-leading health insurer.
In a statement to Strickland, Humana's representative said, "Where it is safe and reasonable to do, Humana and all other insurers ask members to first try alternative therapies to maintain quality and affordability."
The statement went on to say that policy includes the "safe and effective off-label use of certain medications."
Like most states, Georgia has no regulations against Step Therapy. Connecticut and Maryland have enacted limits, and several other states have legislation pending.
Ira Katz, a past chairman of Georgia's Academy of Independent Pharmacy, said Step Therapy can actually increase costs as patients seek additional treatment for the symptoms the cheaper drugs failed to control.
"When they have to go back to the doctor, back to the emergency room, it doesn't make sense." Katz said. "It's penny-wise and pound-foolish."
Strickland found a recent study that stated when insurance companies try to limit the use of more expensive drugs, "Health plans should consider not only ... reducing pharmacy costs, but the broader implication for overall healthcare costs."
Three of the researchers who wrote the study work for Humana.
Allen finally got coverage for Lyrica after three appeals. That means he will pay full price for the drug until he makes his deductible.
"If I had to say something to the insurance company Humana, it would be let the doctors do the doctoring."
WSBTV
