The Problem

the problem

Step Therapy

Patients across Virginia expect that when they sign up for health insurance, they will then have medications and treatments that will help them get better, or at least stabilize their condition with minimal side effects. Unfortunately, that is not always the case, especially when they are forced to go through an insurance practice known as “step therapy.”

Step therapy – also known as “fail first” – occurs when a doctor prescribes a treatment, but the insurance company requires the patient to try one or several other drugs first, with no medical justification. The patient must wait for the doctor-prescribed treatment, often for weeks, months or even years, as he or she tries each of the insurer-mandated drugs one-by-one and proves that the insurer’s preferred treatment didn’t work.

Insurers use step therapy to cut down on medication costs. Sometimes the insurer-mandated drugs can even end up working for the patient. But far too often, step therapy keeps Virginians living with dangerous and even life-threatening conditions – from mental illness and cancer to epilepsy and autoimmune diseases – from the therapies they need, causing adverse reactions and allowing their health to deteriorate.

For providers, step therapy creates additional paperwork and requires arduous back-and-forth interactions with insurance companies as they try to get patients access to medications they need. Often, this leads to unnecessary work and less quality time with patients. Additionally, step therapy second-guesses a doctor’s orders by assuming that the insurance company – not the doctor – knows best. Step therapy protocols have no medical justification.

Both patients and providers in Virginia deserve to have policies in place that make the well-being of the patient top priority.

What should Virginia legislators do to fix step therapy?

Virginia legislators should consider legislation that makes step therapy – or “fail first” – better and safer for Virginians – without inhibiting insurers’ ability to safely use step therapy to save money. For example:

Make step therapy better

Put an online process in place for health care providers to request overrides for step therapy protocols and ensure that providers are notified in writing if the request is denied.

Make step therapy safer

Ensure overrides are granted for Virginians for whom the insurer-mandated drug is clinically determined to cause adverse health events or be ineffective, as well as those who have already met step therapy requirements to receive the same treatment.

Such a proposal would make step therapy more effective at saving money for insurers, the health care system, and the entire state – all while keeping Virginians healthier. By ensuring prompt access to care for those who need it, Virginians would be more likely to miss work and require additional in-patient care, hospitalization, and ER visits.