Understanding Step Therapy

Step therapy, or “fail first,” requires patients to try one or more, typically lower cost, medications to treat their medical condition. Patients must fail on the lower cost medications before the insurance companies allow them to “step up” to another, more expensive medication. These policies can have dangerous consequences for patients. Step therapy bases treatment decisions on cost rather than medical necessity and ignores the safety and efficacy of certain medications for patients.

Only health care providers are acutely aware of the needs of their patient and are familiar with a patient’s personal medical history. Step therapy undermines the professional medical judgment of health care providers, as well as the relationship between a patient and his or her health care provider. Limiting access to life-saving medications disrupts the continuity of care and delays proper treatment, which causes physical, emotional, and financial distress in patients.

The medications that health care providers recommend for patients often vary because the biological makeup of each person is different. Research shows there are gender, racial, and ethnic differences in responses to medications. Limiting access to necessary medications through step therapy greatly widens already existing health disparities.

When a health care provider believes a medication that does not follow a step therapy process is the best choice, they will need prior authorization. Prior Authorization is approval that a health care provider gets from insurers verifying that a medication is necessary. Approval is granted after a health care professional provides sound clinical and medical evidence that the medication is the most suitable therapy for his/her patient. Approval is based on several different factors, including adverse events to the recommended medication and a prior failure with another prescription.