What Is Step Therapy?

Finding ways to manage and treat COPD can be quite a journey. Often, it can feel like there are many different paths to explore, and determining which path works best for your COPD may not always be clear. Add treatment options approved by your insurance company, and it can sometimes add frustration to the journey.

What is a step therapy program?

Step therapy is a type of prior authorization. It got its name from the “step” approach that is required to receive coverage for certain high-cost medications. In order to receive coverage for a particular drug, you may need to first try a proven, cost-effective medication that is on an approved list before the insurance company will approve you to move up a “step” to a more expensive drug.^1,2

Basically, an insurer wants to know that the less expensive medication options don’t work before they will cover the more expensive drug in order to keep costs down for members. Sometimes step therapy is referred to as “fail first” because it can be viewed as failing first-line treatments before being approved for the second-line treatments.¹

Step therapy programs can help manage the rising costs of prescription drugs. They were also created to encourage cost-effectiveness and safe medication use.²

How does a step-therapy program work?

First and foremost, your insurer will want to see that you have a prescription history of what is known as first-line medications before they approve and cover a second-line drug.²

What is a first-line medication?

First-line medication is recognized as a treatment that has an effective and safe history of usage. These treatments tend to be more cost-effective as well.²

What is a second-line medication?

A second-line medication tends to be a less preferred or more costly treatment option when compared to first-line therapy.²

Typically, your doctor will begin by prescribing a first-line therapy that is appropriate for your condition. Sometimes your doctor may find that a first-line treatment is not appropriate for you or your condition or that it is not effective for you or your condition. In these cases, typically the doctor will make the case that second-line therapy is the better option for you. The process for this is called a prior authorization request for the medication. The doctor will complete a prior authorization form for the insurance company.²

What are the pros and cons of step therapy?

Pros of step therapy

Proponents of step therapy argue that step therapy programs help keep costs down and that they also help to minimize risks. Proponents also argue that it allows for the exploration of alternative drug therapies.²

Cons of step therapy

Those who are opposed to step therapy suggest that it can negatively impact patients by exposing a patient to unnecessary or inefficient treatments. Those who are opposed also suggest that step therapy may increase the costs of certain treatments. Many patients and their advocates suggest that step therapy may increase non-compliance and self-medication when patients feel they cannot access the treatment that they prefer.¹

In some states, there is legislation that has been put forth to help better address patient needs. For example, in Illinois, under certain circumstances, patients may be allowed exceptions to a step therapy program. An example of one of the circumstances is if the patient has already demonstrated that treatment failed or they were intolerant to a particular drug, then they could move to the next step treatment. Different legislative topics are occurring at the state and federal levels surrounding step therapy.³