Fail First Therapy or Step Therapy has been a topic I have written about in prior posts. It is my considered opinion that as it works its way into the treatment protocols for advanced prostate cancer it will have nothing but a very negative result for our health and longevity.
What is Fail First Therapy (FFT) also known as Step Therapy? FFT is a process whereby insurance companies decide to control prescribing decisions for our treatments based solely on health care cost savings, not on our doctor’s decisions and not on what might be best for us survivors. Nothing is simply black or white, there is always some grey and this is also true with FFT.
There are times that FFT makes sense; specifically I’m talking about the use of generic versus the more expensive versions of drugs. We are in an economic crisis with our exploding healthcare costs so when drugs are the same I have no issue with an insurance company insisting that the generic drug be prescribed. To take this logic even farther, I can say that in situations where there are two competing drugs both that have exactly the same modes of act an insurance company dictating which of these two drugs should be used is understandable as long as there is a dialogue between the insurance company and the prescribing doctor.
When FFT goes beyond these two conditions, the use of a generic or the use of a drug with the same mode of action, FFT has absolutely no place in our treatment protocols. Insurance companies are not licensed doctors so they have no business in dictating prescribing decisions.
Recently, some insurance companies have taken it upon themselves to institute FFT where they have a preferred drug, Zytiga with prednisone over Xtandi in the treatment of metastatic advanced prostate cancer in the post chemotherapy stage. This means that their subscribers must fail a course of Zytiga and prednisone first before Xtandi would be paid for by insurance coverage. How did they decide on a preferred drug, the answer is simple, its an economic decision. The cheaper drug is the preferred drug because it is cheaper, not be cause it has the same mode of action or is any more or less effective! There is no evidence that either of these drugs is superior or inferior.
This situation can be detrimental. Many men are unable to take prednisone that must accompany Zytiga. There are even some indications that for some men failing a regime of Zytiga can lead to poorer performance of Xtandi!
Malecare has begun to aggressively question the insurance companies that have instituted this type of policy. Commonly, when we receive a response to our protests we are told that both Zytiga and Xtandi have the same mode of action as they both are hormone therapies and so FFT is appropriate. Yes, they both are hormone therapies, but their mode of action is totally different. Zytiga blocks the production of testosterone from the testes, the adrenal glands and from the tumor itself while Xtandi blocks any testosterone that has been produced, no matter from where it is produced, from entering into the cancer cell and supporting its growth. Each of these drugs is hormone therapy, however their mode of action is totally different. These drugs are not interchangeable drugs and only our doctors have the legal right to decide which treatment would be appropriate for us and when it is appropriate.
The really good news is that I have recently learned that we have in fact made one small positive step in resolving this very significant issue for those of us with metastatic advanced prostate cancer. The insurance company, Health Partners in Minnesota has decided to lift its FFT policy in the Medicare Part D space. That means that senior patients covered by this plan will no longer need to first fail Zytiga with prednisone to be able to have insurance coverage for Xtandi when legally prescribed by their doctors in the post chemotherapy stage of treatment.
Personally, I would like to thank Health Partners for they have now taken a step to really becoming our health partner.
Joe T Nowak, M.A., M.S.W.
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