Step Therapy

Step TherapyAn increasing number of insurers are utilizing step therapy or fail first policies requiring patients to try and fail one or more formulary covered medications before providing coverage for the originally prescribed non-formulary or non-preferred medication. Some patients are required by their health plans to try up to 5 different medications with durations lasting up to 130 days per medication.

Where We Stand
  • Step therapy can lead to serious negative patient outcomes and increased costs if not carefully managed.
  • Step therapy needs to be regulated by nationally recognized clinical practice guidelines.
  • Physicians should have the authority to override step therapy protocols based on a patient’s medical history.
  • Override protocols should be clear and abbreviated.

Patients inflicted by a wide-range of autoimmune and related diseases, including Rheumatoid Arthritis, Lupus, Scleroderma, Psoriasis, Leukemia, Lymphoma, Epilepsy, Multiple Sclerosis, AIDS, are being adversely affected. This practice inhibits physicians from being able to provide individualized care, sacrifices valuable treatment time, and may cause patients to suffer unnecessarily.

A physician’s medical decision making expertise in consultation with his patients should drive treatment decisions. Basing treatment decisions on cost rather than clinical considerations ignores important variations that may exist among patients in terms of safety, efficacy and tolerability in drug classes.

Health plans use of such policies also increases the administrative burden on physicians and their staff. Research has shown that for a medical practice to administer insurance each year, the average physician spends a total of almost three weeks a year interacting with health plans, while 23 weeks of nursing staff time and 44 weeks of clerical staff time are required. The national time cost to practices of interactions with health plans is estimated between $23 billion to $31 billion annually.

CSRO has voiced its support for state legislative proposals and supports state rheumatology organizations’ efforts to achieve victory on this front across the country.