- Step therapy, also known as “fail first” or “sequential therapy,” is a cost-control measure used by insurance companies and pharmacy benefit managers (PBMs) to encourage the use of less expensive medications before more expensive ones. With step therapy, an individual with a prescription for a certain medication must first try a less expensive medication (or a set of medications) before the insurance plan will cover the cost of the
originally prescribed medication. - Step therapy is often used for medications that are used to treat chronic conditions, such as diabetes, high blood pressure, and mental health disorders. The goal of step therapy is to ensure that individuals are using the most cost-effective medications available, but it can also be used to encourage the use of generic medications over brand-name medications.
- Step therapy can be frustrating for individuals and their healthcare providers, as it can delay access to the most appropriate treatment. For example, if an individual has tried a less expensive medication in the past and it was not effective, they may have to try multiple other medications before they can get coverage for the medication that their healthcare provider originally prescribed.
- There are some exceptions to step therapy, such as in the case of an allergic reaction or other contraindication to a specific medication. Additionally, some states have laws that limit the use of step therapy or require insurance plans to have an “exception process” in place for individuals who are unable to use the required medications due to medical necessity.
- Overall, step therapy is a cost-control measure that is used by insurance plans and PBMs to encourage the use of less expensive medications. While it can be frustrating for individuals and their healthcare providers, it is important to work with the insurance plan and the healthcare provider to ensure that the individual is
receiving the most appropriate and effective treatment for their condition.
