The Dangers of Step Therapy
Step therapy is a health insurance protocol that requires patients to first try a less expensive drug on a Prescription Drug list before moving up a "step" to a more expensive drug. This approach is also called "fail first” protocol. Unfortunately, the more expensive drug is often the more appropriate and effective drug prescribed by the patient’s doctor.
The step therapy process can take weeks, months or even years – and in the meantime the patient’s health can suffer, especially if the patient is living with cancer, multiple sclerosis, mental illness, rheumatoid arthritis, epilepsy and other chronic or life-threatening health conditions.
Step Therapy policies are used by health insurers to control costs. However, they are time-consuming for the physician and patient, and are actually more expensive from a direct and indirect out-of-pocket cost perspective. Insurance companies are applying step therapy broadly and in so doing, restricting physicians’ discretion, interfering with the practice of medicine and placing patients in jeopardy.
Additional resources and information about step therapy/fail first protocols:
- US Pain Foundation: https://uspainfoundation.org/advocacy/keyissues/step-therapy/
Read/watch these patient stories about their struggles with this damaging insurance practice:
- Georgia boy's family fights insurance company's 'fail first'drug requirement
- Reece's Pieces in a Diabetes World
- Prescription Process Patient Stories
How Georgia Can Fix Step Therapy
Step Therapy can have a place in a reasonable drug plan design. However, sometimes the cheapest drug works and sometimes it doesn’t. Therefore, the plan should be transparent to patients and physicians, and allow for speedy appeals when the insurer-mandated drug is not in the best interest of the patient. We strongly believe the physician should make this decision, not health insurance companies. A dozen states, including Louisiana, West Virginia and Kentucky, have passed legislation to address step therapy. Learn more about the 2019 legislative session step therapy legislation we support.
Rx in Reach GA Coalition (23 member health centered organizations advocating for legislation that ends the financial and discriminatory barriers to securing vital medications) supports legislation that provides limitations on step therapy/fail first protocols.
Georgia House Bill 519 was previously proposed in 2018.
- Ensures that step therapy protocols are based on clinical guidelines developed by independent experts, and
- Establishes a basic framework for when it is medically appropriate to exempt patients from step therapy, as well as an exceptions process that is transparent and accessible to patients and health care providers.
HB 519 Does Not:
- Does NOT prohibit insurers from using step therapy nor limit the number of allowed steps.
- Does NOT prevent insurers from requiring prior authorization before covering a drug.
- Does NOT prevent insurers from requiring patients to try a generic drug if it is equivalent to a brand.
Find out more about HB 519 here.
Join ARxC and the Rx in Reach Georgia Coalition to pass legislation in 2019 so that Georgians have access to the medications prescribed by their clinicians.
July 5, 2018
Learn more about the dangers of step therapy at Fail First Hurts, an initiative led by the Global Healthy Living Foundation to fight against fail first policies in the United States.
ARxC is a proud member of the 50-State Network, a grassroots advocacy organization comprised of patients and patient advocates that are commtted to sharing the patient perspective with state and federal health policy makers. This community is made up of patients living with diverse chronic illnesss, inlcuding rheumatoid arthritis, lupus, and psoriasis, and the people who care about them.
Join the network at https://www.50statenetwork.org/failfirst-join/