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Step Therapy (or Fail First)

What is it?

Step therapy (also known as "fail first") is a policy used by health insurers that require patients to try and fail one or more formulary-covered medications before providing coverage for the originally prescribed non-formulary or non-preferred medication. Insurers implement this policy to control formulary access for the highest rebated drugs, which provides a bigger profit for the insurer and PBM with very little consideration for efficacy.

Why is it important?

Step therapy can lead to serious negative patient outcomes. Some patients are required to try up to 5 different medications with durations lasting up to 130 days per medication. This practice inhibits physicians from being able to provide individualized care, can sacrifice valuable treatment time, and may cause patients to suffer unnecessarily. Also, step therapy can lead to increased costs for patients if it is not carefully managed.

What is CSRO doing about it?

CSRO is the current Chair of the State Access to Innovative Medicine (SAIM) Coalition, which is responsible for the creation of the step therapy reform model language. Each year, CSRO commits resources to state efforts through both SAIM and to its’ state society members to educate and advocate in support of step therapy reform. This includes providing committee testimony, submitting letters of support, attending advocacy days, placing op-eds and social media posts, and sending out action alerts for members to send their own letters to elected officials. 

What can YOU do about it?

Visit our Legislative Map Tool to read about current step therapy laws or legislation in your state. You can send letters in support of pending legislation and find educational materials.