Insurance, Prior Authorizations & Step Therapy

Understanding how insurance decisions are made helps the IBD care plan move faster. This article explains common terms, how prior authorizations and step therapy work, and what to do after a denial. It also lists practical steps and advocacy resources. Rules vary by plan and state, so plan documents and the clinic financial team remain the best local guides.

Key takeaways

• Prior authorization, step therapy, and quantity limits are standard insurance rules, not a judgment on need.

• Fast approvals depend on complete clinical notes, correct codes, and proof of past treatments.

• Denials can be appealed. Ask for the denial letter, timelines, and options for peer review.

• Know which benefit pays. Infusions often bill the medical benefit, self-injectables and pills often bill the pharmacy benefit.

• Copay programs reduce costs, but accumulator or maximizer policies may limit how help counts.

How IBD care is paid for

Health plans pay costs after the member meets cost sharing. Common terms:
- Premium, the monthly payment to keep coverage.
- Deductible, the amount paid each year before the plan pays most costs.
- Copay, a set dollar amount per service or prescription.
- Coinsurance, a percentage of the bill after the deductible.
- Out of pocket maximum, the most a member pays in a year.
- In network, contracted clinicians and facilities with lower costs.

Plan types matter. HMOs usually require referrals and in‑network care. PPOs allow some out‑of‑network care at higher cost. Marketplace, employer, Medicare, and Medicaid plans have different rules and appeal paths.

Medical vs pharmacy benefit

Many IBD medicines can fall under different benefits. Knowing which one applies shapes the process and the bill.

What is prior authorization

Prior authorization is plan approval required before treatment. Plans use it to confirm medical necessity and correct dosing.

A strong submission usually includes:
- Diagnosis and severity, with relevant codes.
- Clinic notes that show symptoms and risks.
- Objective data, such as scopes, imaging, calprotectin, and CRP.
- Past treatments, doses, and why they failed or were unsafe.
- Requested drug, dose, frequency, and site of care.
- Any special factors, such as pregnancy, perianal disease, or intolerances.

Timelines vary. Routine reviews often take several business days, urgent reviews can be faster. Missing documents cause delays. Ask the clinic who is handling the request and how to reach them.

Step therapy, fail first rules, and exceptions

Step therapy means the plan requires trying a preferred drug before covering a different one. Steps may be older drugs, lower cost options, or a specific biosimilar.

Common exception reasons:
- Past failure of the required step, documented in the chart.
- Contraindication or high risk, for example severe steroid side effects.
- Specialist opinion that a step would cause harm or delay.
- Stability on current therapy, also called continuity of care.
- Unique patient factors, for example fistulizing Crohn’s or severe UC.

Ask the clinic to file a step therapy exception with a detailed letter of medical necessity. Include evidence of risks and prior failures.

When a request is denied

Denials are common and can be reversed. Act quickly, since appeal windows are short.

Steps to take:
1. Request the written denial, including reason codes and appeal level.
2. Ask for a peer‑to‑peer review between the plan clinician and the gastroenterologist.
3. File an internal appeal with a stronger letter and more data.
4. If still denied, request an external review when available. State rules apply. Self‑funded employer plans follow federal ERISA rules. Medicare and Medicaid have their own pathways.

Keep copies of all letters, faxes, and case numbers. If health is at risk, ask the plan and clinic about an expedited appeal.

Copays, accumulators, and foundations

Manufacturer copay cards often help with commercial insurance. Some plans use accumulator or maximizer policies. These may allow copay help, but do not count it toward the deductible. Ask the plan if these policies apply, and ask the clinic or employer benefits team about options.

If costs remain high, consider:
- Disease‑specific copay foundations, for example HealthWell Foundation and The Assistance Fund.
- Manufacturer bridge programs that provide temporary free drug during appeals.
- Clinic social work or financial counseling for local aid.

Biosimilars and non‑medical switching

Plans may prefer a biosimilar to a brand biologic. For pharmacy‑dispensed drugs, state law and FDA designations can allow pharmacy substitution. For medical benefit infusions, the plan may direct a switch. Most people do well after a medically supervised switch. If symptoms worsen or drug levels change, the clinician can appeal to return to the previous product.

Practical checklist to speed approvals

Before starting a new therapy:
- Confirm which benefit applies and the preferred product list.
- Give the clinic updated insurance information and any secondary coverage.
- Share a full medication history, including dates and doses.
- Ask about required labs, vaccines, and TB or hepatitis screening.
- Enroll in the manufacturer support program on day one.
- Choose a site of care that is in network and approved.
- Schedule follow up to review the plan response.

For renewals:
- Set reminders for reauthorization dates, often every 6 to 12 months.
- Complete labs on time so the clinic can show continued need.
- Report any missed doses, side effects, or infections.

Advocacy and help

• Crohn’s and Colitis Foundation, IBD Help Center and insurance navigation tools.

• Patient Advocate Foundation, case management and appeal help.

• State insurance department, complaints and external review information.

• Employer benefits administrator, especially for self‑funded ERISA plans.

• Medicare, Medicaid, or Marketplace ombudsman programs.

• Hospital or clinic social worker, financial counselor, and specialty pharmacist.

FAQs

How long does prior authorization take?

Most routine decisions take several business days. Missing records or step therapy rules can add time. Urgent cases can be reviewed faster when a clinician requests an expedited review.

What if coverage changes during a job change?

Ask for a treatment plan summary from the clinic, including diagnosis, current drug, and last dose. Give the new plan this summary and ask for continuity of care coverage so therapy is not interrupted.

What if a biosimilar is required but symptoms worsen?

Contact the care team promptly. They can check drug levels, adjust dosing, or appeal to switch back. Documented loss of response or side effects strengthens the appeal.