What is Step Therapy?
Step therapy is an insurance protocol that requires patients to unsuccessfully try one or more insurer-preferred medications before they receive coverage for the medication that their physician recommends. This practice is also known as “fail first” and can take weeks or months. Once a patient finds a medication that does work for them, they may have to repeat the step therapy process if they switch insurance plans.
Impact on Patients
When implemented inappropriately, step therapy can result in patients not being able to access the treatments they need in a timely manner. This can lead to worsened symptoms and presents a particular challenge for patients suffering from life-threatening or chronic diseases. Physicians can request exceptions to step therapy requirements, but insurers may not respond promptly to such requests, resulting in a further delay of treatment.
The SAIM Coalition supports common-sense limits on step therapy such as establishing clear timelines for insurer responses to requests for exceptions and ensuring that patients who are successfully using a treatment do not have to switch. Click Here to see where the Coalition is working and which states have already passed legislation.