Step Therapy
What Is Step Therapy?
Step therapy, also known as “fail-first,” is a strategy used by health insurance plans to control costs. This utilization management strategy requires patients to try and fail one or more treatment options before pursuing the therapy their provider prescribed. Some fail-first requirements are not even based on clinical guidelines but rather the health plan’s own internal research or financial analysis.
Step therapy so often undermines the patient-provider relationship. However, there are common-sense reforms that a number of states have already implemented, including establishing an accessible and convenient way for providers to request exceptions, requiring a timely response to requests and appeals, and mandating that step therapy protocols are based on accepted clinical guidelines.
Step Therapy Legislative Map
When an insurer denies coverage for a prescribed medication or requires step therapy, it can delay care and create unnecessary administrative burden for infusion providers and care teams. This legislative map was created to help infusion centers, nurses, and healthcare professionals understand the state laws that may apply, including step therapy exception criteria, insurer response timelines, and legal obligations. Use this information to support exception requests and appeals, identify when an insurer may be out of compliance, or take action when no state protections exist by contracting lawmakers to advocate for step therapy reform.
Click on a state to view applicable step therapy protections and requirements.
One thing to keep in mind: Some health plans — including many employer-sponsored plans — are regulated under federal law rather than state law. The plan administrator (often listed on the patient’s insurance card or plan documents) can help determine which rules apply. If a plan is federally regulated and not subject to state protections, providers and patients can still take action by contacting federal lawmakers to support passage of the Safe Step Act.
Step Therapy Action Campaigns
Take action against harmful step therapy protocols by asking your elected officials to support step therapy reform.
