Step therapy (ST) has again reared its most ugly head in our prostate cancer world, to the detriment of us, prostate cancer survivors and only to the benefit of private insurance payers.
So, what is this “creeping crud,” Step Therapy (aka as Fail First Therapy)?
Simply, ST is when insurance companies decide, without sound medical reasons, only for financial reasons, to limit a drugs availability to their subscribers. As referred to by the web site Fail First ST does the following:
“Fail First is used by health insurers to control costs. It is time-consuming from a physician and patient standpoint, is more expensive from a direct and indirect out-of-pocket cost perspective, denies patients the drugs they need when they need them, and allows payers to practice medicine without a license.
- Creates additional barriers leading people to forgo needed medications
- Can cause patients’ medical conditions to deteriorate, increasing the need for medical intervention in the future. As a result, patients require increasingly costly medical care
- Increases frustration and incidents of depression
- Increases the risk of non-compliance and self-medication”
Some of my prior posts have begun the conversation about this terrible, but growing practice. These posts were specific to issues surrounding a developing ST policy requiring the use of Zytiga prior to Xtandi in the post chemotherapy setting of advanced prostate cancer. I have pointed out that currently in the United States there are approximately 88 insurance companies that have instituted this policy without any regard to their subscribers or the underlying medical mode of action of these drugs.
When confronted by Malecare about this practice, the most common response has been that both of these drugs have the same mode of action. They claim that they are both hormone therapies. They both are hormone therapies, but their underlying mode of action is entirely different.
Zytiga + prednisone halts the production of androgens; Xtandi blocks the androgen receptors from allowing the androgens from access the cancer cells. Both are hormone therapies, but each has an entirely different mode of action. In addition, Zytiga requires the simultaneous use of a steroid, prednisone. Many individuals, including diabetics cannot safely tolerate steroids.
I also said that if we allow this practice to continue unabated it would creep into other treatments to the detriment of us cancer survivors. I am sorry to say that I am correct. I have been informed that there is now an insurance company that will not approve the use of Provenge until Zytiga has failed. In the vast majority of the cases a man who has failed Zytiga will not qualify under the FDA approved label for Provenge. This ST policy is a poorly disguised and disgusting attempt to make it so that a man will never be able to have Provenge and gain from its benefit (living longer). However, it will save the payer a huge amount of money.
It is important that we all understand the can of worms that has been opened. Not only has the can been opened with the Zytiga and Xtandi issue,the can has been tipped over and the worms are crawling into other of our treatment protocols. This problem has already affected our health and our survival.
Joel T. Nowak, M.A., M.S.W.