A woman climbs up a very large flight of steps towards several medications that are out of reach

Is Step Therapy Impacting Your Care?

Finding ways to treat chronic hives can be a long and difficult process. It might mean taking prescription medicines and specialty drugs that are quite expensive. This is where step therapy comes into play.

Insurance companies claim that step therapy helps to cut down on drug costs. But many find it to be controversial. Patients and doctors argue that step therapy negatively impacts care and prevents people from getting the medicines and drugs they need to treat their medical conditions.1-4

What is step therapy?

Step therapy is a process used by insurance companies. It requires you to prove that lower-cost drugs are ineffective before you can “step up” and get coverage for a more expensive, higher-tier drug.1-3

Step therapy is a type of prior authorization. Prior authorization means that insurers need to approve coverage of a certain medicine before they will pay for that drug. It only applies to people who have health insurance.1

How does step therapy work?

Your doctor prescribes you a treatment plan. This treatment plan may include certain medicines to take as part of your journey. Step therapy classifies medicines in 2 ways:1

  • First-choice drugs – These drugs are cheaper and designated safe and effective for a condition. These often include generic versions of brand-name drugs.
  • Second-choice drugs – These drugs tend to be less preferred and more costly for health insurance to cover.

When a first-choice drug is not right for your health condition, your doctor may prescribe you a second-choice drug that is a better option but more expensive. This requires a prior authorization request for the medicine. Your doctor completes a prior authorization form and sends it to your insurance company for approval.1

Why is step therapy controversial?

Step therapy is controversial because it can delay access to medical treatment. This delay can lead to even more health concerns and greater healthcare costs down the road. For people with a rare disease like chronic hives, this is very concerning.3

The lists of drugs that require step therapy can also vary depending on the type of health insurance you have.

Conditions most often affected by step therapy

A 2021 study found that certain medical conditions were more prone to having step therapy involved. Of these conditions, step therapy was used in more than 70 percent of the policies that were involved in the study. And in more than half the cases, step therapy protocols were more strict than clinical guidelines.2

Those conditions most often affected by step therapy include:2

  • Chronic migraine
  • Crohn’s disease
  • Psoriasis
  • Ulcerative colitis
  • Rheumatoid arthritis
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Polyarticular juvenile idiopathy arthritis
  • Multiple sclerosis
  • Hepatitis C

Chronic diseases, like the ones above, can last throughout a person’s life. They often require a trial-and-error approach to treatment. But when step therapy is involved, it adds another layer of complexity that can further delay access to quality healthcare.

What to do if you are denied coverage

If your insurance company denies coverage of a drug, you are responsible for the full cost of that drug. But there are options:1

  • Issue an appeal. Ask your doctor to help gather any medical documents or notes that might help your appeal. Keep in mind that not every insurer allows for step therapy appeals, so check with them first.
  • Consider other medicines. Ask your doctor about alternative medicines you can take that do not require step therapy.
  • Check to see if you qualify for a patient assistance program. This can help you save money on prescriptions.
  • Ask your doctor if they have samples of the preferred drug they can give you in the meantime. This might be an option if you are waiting for an appeal to be approved and urgently need the medicine.

Reforming step therapy

Many states are working to reform step therapy. More than half of US states have protections in place to help people get the right therapies at the right time. An example includes faster approval timelines for emergency and non-emergency situations so there is no lapse in treatment.3

The “Safe Step Act” is another way step therapy is being reformed. It is a bipartisan bill that was introduced to the Senate and House of Representatives in 2021. Its goals include:4,5

  • Ensure all people have quick access to treatment
  • Reduce overall administrative costs for the US healthcare system

Advocate for yourself

If you are unsure whether a prescribed drug will require step therapy, contact your insurer. If step therapy is impacting your care, talk with your doctor. Know your options so you can get the treatment you need.

Have you or a loved one had medical care impacted by step therapy? Share with us in the comments below!

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