patient reviewing insurance information/step therapy

Step Therapy is a Step in the Wrong Direction

November 6, 2023 | Rheumatic Disease


Many individuals who have been prescribed medications for a rheumatic disease have been in a situation in which their rheumatology provider has prescribed a specific medication, but the insurance company has denied it stating they prefer an alternative medication for treatment. This occurrence is all too common within rheumatology and is known as “step therapy.”

“Step therapy,” also known as “fail-first,” is a policy developed in the 1980s by health insurance (private or public) companies. This policy is intended to control costs of prescription drugs by requiring a patient to try a lower-cost prescription drug before “stepping up” to an alternative drug. In other words, if the insurer believes there is an alternative medication to the one your doctor prescribes, you are required to use that one first.

The increasing costs of prescription drugs have led health insurers and their pharmacy benefit managers to limit their formulary (“preferred”) medication. The insurer may also require multiple medications to be tried and failed before they agree to pay for the one the doctor originally determined was best for the patient. While insurers do this as an attempt to control healthcare costs, it has been applied without regard for the patient’s medical situation or urgency.

Within step therapy, patients often encounter problems when their insurance status changes due to switches in jobs or employer-sponsored coverage. This means that patients can unexpectedly be subject to new step therapy requirements forcing them to switch from the medication that they have been on for extended periods of time to whatever medication is “preferred”. Your physician can appeal this decision, but the insurer may take four to eight weeks and require numerous communications which your doctor before it is approved. In this time, disease may progress and physical damage may occur. Furthermore, health insurance companies do not have to consider the side effects that may arise from their substitute medication.

The American College of Rheumatology (ACR) has been vocal about step therapy reform and has established the following firm positions:

  1. The ACR supports strategies for lowering the cost of expensive therapies but opposes cost savings plans that compromise quality of care or safe clinical practices.
  2. The ACR does not support step therapy, fail-first policies or tiering of medications based solely on cost.
  3. Access to medically necessary treatment should be timely and not impeded or delayed by unnecessary barriers.
  4. All healthcare stakeholders deserve transparency in formulary decision-making processes.
  5. Pharmacy review committees should involve rheumatologists when developing formulary benefits programs. The ACR welcomes the opportunity to provide expertise regarding rheumatic therapies to insurers.
  6. Non-medical switching between branded products and across therapeutic classes in a medically stable patient solely for cost savings and without the consent of the patient and his/her provider is inappropriate and potentially harmful to patients' health.

ACR members visit federal representatives in Washington D.C. twice per year to advocate for policies that optimize care for our patients and clinicians.

Learn more about step therapy and how you can #Act4Arthritis

Mohammad A. Ursani, MD

About the Author

Mohammad A. Ursani, MD

Mohammad A. Ursani, MD, is a private practice rheumatologist in The Woodlands, Texas, and serves as a Chair of the American College of Rheumatology Communications and Marketing Committee. He also currently serves as a Delegate in the Texas Medical Association and is a Young Physician Ambassador for the Harris County Medical Society.

We use cookies on our website to improve our service to you and for security purposes. By continuing to use our site without changing your browser cookie settings, you agree to our cookie policy and the use of cookies. See ACR Policies