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Step Therapy

Step Therapy is a health plan’s cost control process that makes a patient try first a medication treatment decided by the insurer and fail with that drug before the health plan will pay for the patient’s medication prescribed by the doctor. This “fail first” approach often results in reduced medication adherence and can lead to serious health risks while the patient goes through the steps and failures.

More than half the states have passed legislation authorizing an exception to step therapy. However, even if a state has exception legislation in place, it can’t address the issue when the patient is insured by an Employee Retirement Income Security Act (ERISA) health plan. Consequently, federal legislation (HR 2163/S 464) is needed and is currently being considered by congress.