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‘Fail First’

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Mary Ellen Decker had scanned the letter she’d received, written in opaque bureaucratese, about her health insurance, but it didn’t seem to day much. So she was taken by surprise when her prescription for Celebrex—to help control intense pain after a steroid shot for arthritis in her thumb—was denied.

Instead, the pharmacist told her to try Tylenol.

This is the letter Decker received. Click here for a PDF of the full letter.

“I was furious—I was in agony!” she remembers. But her pharmacist was just following orders.

Decker’s district, Dunkirk City Schools, southwest of Buffalo, New York, had unilaterally switched her prescription drug coverage to a system euphemistically called “step therapy,” but also commonly—and more realistically—known as “fail first.” That is, before you get the expensive drug your doctor thinks you need, you first have to try and fail with other, cheaper drugs.

Decker, who unfortunately has a great deal of experience with arthritis-related pain and the efficacy of various pain medicines, knew that Tylenol wasn’t going to ease her suffering.

What did help was Decker’s skill at arguing over the phone. Two days and several phone calls later, insurance representatives relented and her pharmacist was able to fill her prescription. In the meantime, she’d taught her regular high school class load in constant, excruciating pain.

Local union president Joe Sweeney says more than a quarter of his members made the unpleasant discovery that their pharmacists couldn’t fill their prescriptions. Doctors are allowed to appeal a rejection, but that takes time. One member couldn’t get his heart medicine because his doctor was on vacation.

That was not the kind of drug coverage the union and the district had agreed to at the bargaining table. Their contract had a clause guaranteeing no benefit reduction without negotiations. So Decker, who happens to be her local’s grievance chair, filed a grievance. The district argued that “step therapy” was just a change in procedures, not coverage, but they failed to convince the arbitrator. Educators in Dunkirk no longer have to suffer through drug failure before they can follow their doctors’ advice.

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