Step therapy occurs when your insurer requires you to use medication alternatives before another, possibly more expensive, treatment option. Depending on specific factors, you can work with your doctor and appeal this decision.

When a doctor writes a prescription for a medication, your insurance company may not always agree to cover that particular medication at first.

One way insurers use to restrict certain medications is known as “step therapy,” a way to get people to try lower-cost or “preferred” brands first. This is a sort of first step, meaning the insurance company may want you to try that alternative for a period of time to see if it works for you.

If that alternative is not effective, they may then reevaluate another prescribed medication that might be non-preferred or higher cost, as a next step.

Step therapy is a protocol that requires a patient to try one or more lower cost, “insurer-preferred” medications first before the insurance plan will cover a similar, but more expensive, drug originally prescribed by their doctor.

The insurer’s primary goal is to ensure that you are getting the most reasonably priced and effective medication available, ultimately lowering the health plan’s overall prescription drug costs.

  • Steps: Medications are grouped into steps, possibly including one or more initial steps before you reach higher steps that could allow your doctor to prescribe the originally prescribed medication.
    • Step 1: Includes less expensive options, often generic drugs or certain lower cost brand-name drugs, which the insurer prefers you try first. These are usually covered without any issue and may have the lowest copay.
    • Higher steps: Depending on the number of alternative drugs and what your particular insurance plan covers and considers a “preferred” drug, there could be several of these steps. These typically include the more expensive, sometimes non-preferred, brand-name medications that require you to have failed on the lower-step options first.

Typically, an insurance company wants documentation showing the length of time the medication was used and its health effects before proceeding to higher-cost medications in later steps.

While this is a common tool used by insurance companies and one of the key ways insurers try to limit costs, the medical community views it with skepticism.

Many in the medical community view it as “fail first,” as you must demonstrate that the lower cost medications were ineffective or caused unacceptable side effects before the insurer will approve coverage for the higher-cost drug your doctor initially prescribed.

For physicians, this is often viewed as a type of non-medical switching as the insurer puts a barrier in place that goes against what the doctor has already discussed and prescribed to their patient.

Step therapy can have negative effects on your course of treatment and overall health:

  • Delayed access: One negative effect is the potential for a delay in receiving the medication your doctor believes is best for your specific condition. You may have to endure weeks or months on a drug that is less effective for you before the preferred medication is covered.
  • Worsening condition or health risks: For those with serious, chronic, or progressive conditions (like rheumatoid arthritis, certain cancers, or mental health disorders), a delay in effective treatment can lead to a worsening of symptoms, irreversible damage, or other health complications.
  • Need for exceptions: If your doctor determines, based on your medical history, that the “step 1” drug is likely to be ineffective, harmful, or you’ve already failed on it under a previous plan, they can request an exception (or “prior authorization“) from the insurer to bypass the step therapy requirement. This process, however, can be time consuming.
  • Change in coverage: If you switch insurance plans, you may be required by the new insurer to start the step therapy process over, even if you were already using a higher-tier medication. This may require your doctor to show past documentation that you’d tried and used the lower-step medications and they weren’t effective treatment options for you.

If your insurance company requires step therapy before it allows a different specialty or brand-name medication, you may consider the following actions:

  1. Consult your healthcare team: Talk with your doctor about options. They may be able to appeal a step therapy, especially if you’d already tried and “failed” on the lower-tier medications the insurer prefers.
  2. Do your research: Know what medications you may need to consider, how they work, and whether cost elements such as a lack of coverage or higher pricing may affect your treatment and care plan.
  3. Keep medical history documents: Make sure you have copies of any medical records or a history of the medications you’ve taken, in case you may need to later prove that you’ve used them. Your doctor’s office will likely have these on file that you can discuss having a copy of to have on hand, especially if you’re changing health plans or going to a new clinic and physician.
  4. Appeal to your insurance company: If you believe you’ve met step therapy criteria or do not need to follow step therapy protocols, you can work with your healthcare team to appeal an insurance company’s decision on step therapy.

Step therapy is a measure insurance companies use to contain costs and manage the types of medications you take.

While this may lower insurance costs by encouraging lower-cost drugs, step therapy is viewed negatively by many doctors because it creates a barrier for patients to access what the doctor has prescribed.

There are ways to appeal this decision, if you and your doctor agree a different medication is needed and you’ve met or may be able to bypass an insurance company’s step therapy criteria.