Who is in charge of health care? Vancouver woman’s doctor prescribed a medication but insurance denied it four times

“Lesser cost alternatives may be available, including mere observation, or, where appropriate, no medical treatment at all,” a Feb. 7 letter from Molina Healthcare states.

Molina Healthcare maintains that genetic tests do not confirm whether a patient will be nonresponders to a particular drug.

“I’ve never had insurance shut me down so blatantly,” Wright said. “I’m not the only one, but I can’t stop feeling like it’s intentional. There have been so many hard days where I know if Molina had just given me that antidepressant, it would have started working by now, and I could start getting my life back in order.”

Molina Healthcare did not respond to multiple requests for comment before The Columbian’s deadline. However, in a separate Feb. 4 letter to Wright, the health care company states Wright must first try and fail treatment with two preferred drugs — duloxetine (Cymbalta) and venlafaxine (Effexor) — before it would cover desvenlafaxine succinate (Pristiq), the antidepressant her genetic test indicated would be the safest option.

“As you may be aware, the American Psychiatric Association does not recognize these genetic tests for initial medication selection,” Molina Healthcare wrote Feb. 4. “These genetic tests demonstrate how a patient metabolizes a drug, but does not confirm they will be ‘non-responders’ to certain medications. Your doctor must show you failed a trial of two preferred drugs. Or your doctor must show why the preferred drugs are not right for you.”

Wright said she has appealed the decision with Molina multiple times since the company’s original denial came in January, but it continues to impose step-therapy: a health care policy that requires patients to try less expensive medications before covering a medication that costs more.

Amazon Pharmacy lists Pristiq at about $370 for a 30-day supply without insurance, but prices elsewhere are listed around $570 a month. Duloxetine, available as a generic, costs about $10 a month, and venlafaxine ranges up to $135, depending on the dose.

By design, step-therapy and similar strategies can create administrative burdens aimed at steering patients and physicians to an insurer’s preferred treatment, according to a study from the National Library of Medicine.

Wright plans to file a complaint with the Washington Office of the Insurance Commissioner, a small agency of about 280 employees who oversee the insurance market statewide. The agency has the authority to investigate complaints about a patient’s insurance company or agent and propose laws when consumer protections are needed, according to its website.

Stephanie Marquis, public affairs director for the insurance commissioner’s office, said there are no regulations that require insurers to consider genetic testing when determining prescription coverage. However, a new bill this legislative session could change that.

House Bill 1425, sponsored by Rep. Lauren Davis, D-Shoreline, would require coverage of pharmacogenetic testing for psychotropic medication, which includes antidepressants, antipsychotics, mood stabilizers and more.

If passed, health plans — including health plans offered to public employees and through Medicaid — issued or renewed on or after Jan. 1, 2026, must provide coverage for pharmacogenetic testing. Health plans, the Health Care Authority and Medicaid managed care organizations would not be able to impose prior authorization or step-therapy requirements to this form of testing, according to the proposed bill.

Wright is insured through Washington’s Medicaid program, Apple Health, but she began coverage with Molina Healthcare in 2024 as a supplemental insurance because it covered a wider range of health care providers in Clark County, she said.

Up until now, Wright was happy with her decision.

“Every single day in February has been spent fighting with Molina. The genetic test gave the result that Cymbalta and Effexor would not work for me,” Wright said. “At worst, it will hurt or kill me. At best, it just doesn’t do anything. I have been on medications in my past that have nearly killed me.”

Tug-of-war

Mental health has been a struggle for Wright since she was 5 years old, she said.

In addition to a yearslong battle with depression and anxiety, Wright has polycystic ovary syndrome, known as PCOS, a chronic condition that causes irregular periods, excess hair growth, weight gain and other symptoms.

On Jan. 29, Siefe wrote a letter advocating on behalf of Wright after coverage for the medication was first denied by Molina Healthcare.

“With psychiatric medications, often we have historically done a trial and error approach where patients have had to try multiple medications before figuring out the ones that work best for them,” Siefe wrote.

Siefe said it is well known in medicine that if a patient’s family member does well on a medication, that patient is much more likely to do well on it, too.

“This just shows the genetic component of these choices of medication, and why it is such a gift that with modern testing we can know which medication is likely to do best with her genetics,” Siefe wrote. “This area of study is called pharmacogenetics and is likely to be the future of medicine.”

“If we have objective data reporting that it is contraindicated to trial two medications, it goes against my oath as a physician to subject my patient to trying serious side effects that may not work well,” Siefe wrote.

So who has the final say?

According to the insurance commissioner’s office, when a patient’s health insurance rejects a treatment or a bill dispute, that doesn’t have to be the final word.

Patients have the option to file an appeal to their insurance provider, but if the answer is still no, they can file another appeal with an independent review organization.

A health insurance company cannot change, reduce or stop benefits for an ongoing course of treatment without providing you advance notice and an opportunity for review, according to the insurance commissioner’s office.

But Wright believes Molina Healthcare should not have been able to dismiss genetic testing within its denial in the first place — as does Siefe.

“I sincerely hope that insurances will start to consistently acknowledge the validity of these tests and then respect the patient/doctor combined decisions on best medications especially in psychiatric medicine,” Siefe wrote.

Insurance roadblocks

Claim denials by insurance companies were highlighted by national media outlets following the shooting death of UnitedHealthcare’s CEO Brian Thompson, which sparked further discussion about patient autonomy and the quality of the United States health care system.

According to an analysis of federal health care data by ValuePenguin, UnitedHealthcare and Molina Healthcare were among the top 10 companies with the highest claim denial rates.

UnitedHealthcare had a 33 percent denial rate, while Molina Healthcare followed closely behind with a 26 percent denial rate, according to the December report by ValuePenguin that analyzed data from the Centers for Medicare & Medicaid Services.

Kaiser Permanente and Providence Health Plan were among insurers with the lowest denial rates. Kaiser has a 6 percent denial rate, while Providence had a 4 percent denial rate.

ProPublica, a nonprofit newsroom that investigates abuses of power, published a series of articles in 2022 called “Uncovered” that shed light on insurers’ rejections of millions of claims every year in the United States.

One article in the series uncovered that many of the country’s largest insurers delegate medical reviews to EviCore, a company that determines whether to approve care for more than 100 million people.

While data on insurers’ claim denials remains limited, ProPublica found available government figures indicate that insurers reject between 10 percent and 20 percent of submitted claims.

“And what information it has released, experts say, is so crude, inconsistent and confusing that it’s essentially meaningless,” ProPublica said.

‘Keep fighting’

Wright said throughout the denial process with Molina Healthcare, she’s been leaning on her partner, Jacob Christensen, writing down her feelings and finding comfort within online gaming communities.

“I tend to hyperfocus on my comforts,” she said.

After Wright files a complaint with the insurance commissioner’s office, she wants to go one step further and request an external review of her case.

External reviews are performed by independent review organizations that aren’t affiliated with an insurance company. The review can either uphold or overturn the insurance company’s position, according to the insurance commissioner’s office.

Once an independent review organization considers an appeal, that decision is final.

In the meantime, Wright wants to advocate for change within the health insurance industry. She wants others who find themselves in a similar situation with an insurance company to know that they should keep fighting.

“I want to change things. I am going to change things. It is angering because it feels like Molina is intentionally dehumanizing and depersonalizing me,” Wright said. “It feels like they just want me to continue to be depressed until I just give in and die.”