Why Healthcare is Embracing a Fail First Policy

Has your doctor ever given you a prescription and then you found out your insurance won’t cover it? They probably said something along the lines of, “you need to try this generic/cheaper version first. If that doesn’t work, then we’ll consider the medicine your doctor actually prescribed.” Well, they’re probably not quite that honest. This is what we know as “step-therapy” – which we usually call fail first policy. It’s increasingly common among insurance plans and if you haven’t seen it yet – just wait!

Fail first policy

Fail first essentially supplants your doctor’s recommendations with your insurance company’s formulary. Sometimes its minor. My insurance company won’t pay for the brand of inhaler my ENT recommends but they will cover a similar generic. It doesn’t work as well but they’ll cover it.. But it’s not limited to inhalers – fail first also affects thousands of other medications for chronic pain, diabetes, Alzheimer’s, COPD and many more.

Right now, it seems limited to prescription drugs. It’s no secret that the cost of drugs is increasing – 11% last year alone – and insurers are under enormous pressure to cut costs and keep premiums down. But what happens when cost undercuts quality? What good are limits that are set entirely by insurance fail first policycompanies without review by physicians, patients or the department of health?

Check out the Global Healthy Living Foundation for more information on the consequences of Fail First therapies including depression, increased medication non-compliance and deterioration of chronic medical conditions. The law currently does not limit the length of time a patient needs to use the alternative product. Before getting a prescription for the thing they need – for some it’s nearly 6 months!

There are literally dozens of stories out there about patient’s suffering under fail first. We hear about it all the time at Men’s Liberty. While fail first doesn’t yet cover medical equipment like Liberty, many of our clients have multiple issues alongside their incontinence so they tell us all about it. Some insurance companies will even try to take the same tactic with Liberty saying a patient needs to fail first with a condom catheter before they will cover the Liberty. It’s simply unacceptable for patient’s to be forced to use a product or medication that won’t work before insurance companies pay for one that will.

So what can you do?

FL State Senator Don Gaetz posted one solutiondin the Tampa Bay Times this weekend. His “Right Medicine, Right Time Act” would require insurers to have a step protocol reviewed by the Department of Health. That would ensure that any step protocol meets a basic “burden of proof” when supplanting their judgment for a doctors. The bill failed in the last session but it’s coming back in January 2016. And you can get involved to make sure this time it passes!

To get involved here in FL or to get similar laws passed in your state – write or call your State Representative and State Senator. You can also share your fail first story, talk to your friends and family. Or even ask your insurance company about it! You and your loved ones deserve better than fail first – demand better, we’re beside you all the way!


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