Step therapy, also known as “fail first,” is a process used by health insurers to control costs. It requires patients to try one or more medications specified by the insurance company, typically a generic or lower cost medicine, to treat a health condition. Patients must then fail on the medication(s) before allowing a “step up” to another medicine that may be more expensive for the insurer.
It’s a familiar scenario for most of us. You get sick and go to the doctor. Your doctor takes your medical history, examines you, and makes recommendations about your treatment. Your doctor writes you a prescription. But, for many patients, the process of getting the medication prescribed by their doctor may be far more complicated.
Sometimes, getting the medication your doctor prescribes can be very complicated. That may be due to insurance policies such as step therapy.
Also known as “fail first,” step therapy requires patients to take other medications and fail on them before the health insurer will pay for the medication originally prescribed by their doctor.
Step therapy is used by insurers to limit how much they spend on certain medications. Under step therapy, patients must try one or more drugs chosen by their insurer - usually based on financial considerations - before coverage is granted for the drug prescribed by the patient’s health care provider.