Step Therapy/Fail First
Issue Brief VideoAdvocate Achievements State Legislation Map
Watch our short video about Step Therapy, learn about the practice and how it can affect people with arthritis.
- Step therapy is a practice used by insurers that requires people with arthritis to try lower-cost medications before allowing more expensive treatments, despite a physician’s recommendation
- As a result, more expensive effective drugs can only be prescribed if the cheaper drugs prove ineffective
- When a person changes insurers, or a drug they are currently taking is moved to a non-preferred status, the person may be put through the step therapy process again
- Permit a physician to override the step therapy process when patients are stable on a prescribed medication
- Permit a physician to override the step therapy if the physician expects the treatment to be ineffective based on the known relevant medical characteristics of the patient and the known characteristics of the drug regimen; if patient comorbidities will cause, or will likely cause, an adverse reaction by, or physical harm to, the patient; or is not in the best interest of the patient, based on medical necessity
- Require an expedited process of no more than 24 hours in cases of emergency
- Require health insurance plans to maintain step therapy approval and override request processes electronically
- In circumstances where a patient is changing health insurance plans, the new plan may not require the person to repeat step therapy that was completed under a prior plan
- A survey of more than 1,400 patients conducted in 2016 by the Arthritis Foundation revealed that over half of all patients reported having to try two or more different drugs prior to getting the one their doctor had originally ordered. Step therapy was stopped in 39 percent of cases because the drugs were ineffective, and 20 percent of the time due to worsening conditions. Incredibly, nearly a quarter of patients who switched insurance providers were required to repeat step therapy with their new carrier
- At the federal level, Representatives Brad Wenstrup (R-OH) and Raul Ruiz (D-CA) introduced the Restoring the Patient’s Voice Act of 2017 (H.R. 2077). The bill mirrors model state legislation and applies to employer-sponsored health plans
- To date, states have passed laws instituting patient protections for step therapy protocols
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