Few people are familiar with the term “step therapy,” but most Americans have health insurance policies that adopt it. Step therapy programs, also known as “fail first policies,” require patients to try less expensive treatments before insurers agree to pay for more costly alternatives. Thus, insurers can deny coverage for a drug your doctor prescribed because you haven’t found other, cheaper medications to be ineffective first. As many as 75 percent of large employers have insurance plans with step therapy, and Medicare is increasingly embracing this approach as well.
My husband and I encountered step therapy when he was prescribed a new medication for his Parkinson’s disease. As a professor of law and bioethics, I have since researched and written about this phenomenon. I have found that step therapy can be sensible in some instances, but it also raises important concerns and should be carefully regulated.
Benefits and Risks of Step Therapy
Health insurers have good reason to be worried about health care costs and to try to limit them. Medical costs have famously ballooned in recent years. According to a congressional report, “the prices of many of the most popular brand-name drugs increased at nearly ten times the cost of inflation from 2012 to 2017.” Thus, it often makes sense to require patients to try cheaper but equally effective choices, such as generic rather than brand-name drugs.
However, in some cases, step therapy can increase costs in the long term, even if it lowers them in the short term. It can also significantly hurt patients. This is because doctors may have very good reasons for prescribing particular drugs for specific patients. In such cases, individuals forced to take different medications can suffer severe side effects, complications and health deterioration.
For example, Eitan Kling-Levine, an ulcerative colitis patient, was required to take several…