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.