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What is a fail first option?

When you are recovering from a serious personal injury, perhaps resulting from an auto accident or a Kentucky workplace incident, you do not want an insurer to play games with your medical care. However, some insurance companies are making it harder for their policy holders to receive the best care possible. One of these ways is forcing people to go through “fail first” options.

U.S. News and World Report explains how a fail first option works. Your doctor prescribes a drug for your condition, but your insurer does not cover the drug, at least not at first. Instead, the insurer will steer you toward trying out an alternative drug that is cheaper. The idea is that if this cheaper drug works, the insurer will cover that drug instead of the one originally prescribed and save money in the process.

However, a fail first option is very risky. The drug may not work at all, which costs the patient valuable treatment time. The patient may spend months on the cheaper drug before the insurer admits the drug does not work and agrees to cover the drug you were prescribed to begin with. By waiting so long to take the right drug, the health of the patient could be endangered.

Additionally, trying a cheaper drug can produce side effects or other health problems. Even if the drug is similar to the one a patient was prescribed, it may act on the body in ways that newer drugs are meant to prevent. Also, the doctor may know that cheaper drugs are not appropriate for the patient, which is why the original drug was prescribed in the first place.

To the frustration of some patients, they may go through a fail first process to get to the point where they can have their original medication covered, but then there is a change in the management of the insurer. Sometimes the new leadership will actually require patients to go back and repeat the fail first process all over again. This can happen even if patients have had no luck with the cheaper drugs to begin with.

Medical insurers should not put your health at risk. Professional legal counsel can help you through all the legal steps needed to win compensation and alert you when someone is playing around with your medical coverage. Be aware that personal injury claims take many forms, so do not consider this article as legal advice. Its sole purpose is for educational benefit to the reader.

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