NEW ORLEANS -- What do you do if your doctor prescribes a medication, but your health insurance company denies it, telling you to take a cheaper one? But what if the cheaper medication doesn't work? What do you do?
One doctor is speaking out about the battle she and other doctors face daily.
Sue Crescioni has genetic high cholesterol. Medicine protects her from heart attacks and strokes.
Years ago, board certified internal medicine specialist Dr. Tania Levi put her on a lower cost prescription. It's called a tier one drug by insurance companies. It did not work.
Then, success. A name brand, higher cost prescription, called a tier two drug, perfectly controlled this chronic, dangerous condition.
'It's basically like dropped my cholesterol like over 100 points. Yeah, without any side effects, and I've been on other medications before and I've had side effects,' said Crescioni, a Mandeville resident.
But in January, Crescioni's health insurance company changed its formulary, which contracted list of preferred medicines. New rules meant Dr. Levi now needed prior authorization to continue prescribing Crescioni the drug that has perfectly managed her high cholesterol for two years, but first the insurance company said she had to go back on the failed cheaper drug.
'Why should it be an insurance company's decision as to what medication I'm on? I think that my physician should be the one dictating what medication I'm on. She has my history. She has evidence of what this medication has done for me,' said Crescioni.
'There is no way on the face of this earth I'm going to give her that drug that failed three years ago to have it fail again when she's on treatment and stable. That's malpractice,' Dr. Levi said emphatically.
Dr. Levi runs the Northlake Medicine and Wellness Center in Covington and even helps manage diabetics' glucose by showing them how to exercise on her in-office equipment.
Crescioni's insurance company denied her. She was no longer allowed to take the tier two medicine that works, unless she went back on the failed tier one medication for months, failed again, and then documented it.
'Unfortunate. The all mighty dollar is what is dictating this,' said Crescioni.
Crescioni knows tier two medications mean a higher co-pay, but she has no choice. Doctors are sick and tired of fighting what the insurance industry calls step therapy.
Dr. Levi calls it prior authorization on steroids.
'Now, not just get permission to go from tier one to tier two. I am required to use the tier one drug and prove that I've used it, even if I feel it may not be effective or could be dangerous, before I can get the brand name drug.
'That's the dreaded step therapy. That's when, in my opinion, things started becoming dangerous, because I went to school from age 6 to 30 continuously. I've done this for two and a half decades in this community, on these patients. Who should decide what medications they get, me or some chick in a miniskirt in another state looking at a computer who is beholden to the CEO and the shareholders of a for profit company? Who should decide?' Dr. Levi said. 'I think that's clear. I should decide.'
One women had a virus that caused both chronic nerve pain and depression. One tier two drug fixed both, but the insurance company wants her to take a tier one generic, but there is no generic for the drug. So insurance is telling Dr. Levi to prescribe two separate tier one drugs that she says won't be as effective.
'It shouldn't be any fighting whatsoever, because most health plans, if you have tried that generic between that four and six-month period and for any reason, for any reason if that doctor, patient contacts and says it's not working or they're having side effects, almost every health plan will automatically go to tier two,' responded Jeff Drozda, the CEO of the Louisiana Association of Health Plans in Baton Rouge. This agency represents the insurance industry in the state.
The insurance industry says that four to six-month period for trying a generic was professionally determined because patients' bodies change and tier two drugs can be eight times more costly than tier one. They say both healthy patients and low premiums for customers are the goal.
'If a patient or a doctor feel that tier one does not work, they just make the request and most health plans will automatically approve that tier two. The studies show that if you don't take your, if you can't afford your medication, you're not going to take it, and that's not in the best interest for a health plan or physician, or most importantly for a patient,' added Drozda.
He said prior authorization is a click of a form online. But Dr. Levi and her staff spend hours a day, filling out one of 219 different forms for prior authorizations. There are cases after cases of denials and appeals with 30-day waiting periods.
'I've got to do something because failure is not an option. I have to get the patient the medication,' Dr. Levi insisted.
She constantly asks pharmaceutical companies for special programs and samples. She says Medicaid has only one prior authorization form. But the insurance industry says doctors wanted all the forms, one for each illness.
'No one's telling any doctor how to practice medicine. Matter of fact, most, I should say every single health plan, at least in Louisiana, they have doctors. They have nurses on staff in terms of how they determine what's on their formulary. They have doctors, physicians, pharmacists that all come together to determine what is the best medication to put on which tier,' explained Drozda.
'Why should a professional person, who's trying to do her job to take care of American citizens, be forced to either violate her oath or violate the law in order to do what I know is right?' Dr. Levi said. 'Why should I go through that every day? I can tell you, that is why physicians my age (early 50's) and older are getting out of the business. They're sick of it. They're burned out. They don't see hope for the future. I'm going to fight and I'm going to get the patients the medications they need, but we need help. We need some relief from this system.'
Dr. Levi is now attaching 'Act 144' to the denials she is appealing. It's already on the books stating that doctors can challenge step therapy decisions. She says most doctors don't know about it.
She is waiting to see if it has any teeth in overturning her patient denials.
There is also a bill in this session calling for fewer prior authorization forms.