Frequently Asked Questions

How does step therapy happen?

Step therapy – or “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.

For example: You go to your doctor, who prescribes a therapy to effectively treat your condition, based on your unique health history. Your insurance company refuses to cover the treatment your doctor prescribes, until you try, and fail on, three other treatments – drugs A, B, and C.

Why is step therapy used?

Insurers use step therapy to cut down on medication costs, and sometimes the insurer-mandated drugs can even end up working for the patient. However, step therapy can actually increase costs. It creates the need for more doctor visits. Plus, the insurer-preferred medications can cause side effects and negative health consequences that can even require hospitalization.

Why can step therapy be harmful for Virginians?

Often times, 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.

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.

For Virginians who rely on prescription therapies to stay healthy, productive and out of the hospital, step therapy increases health care and societal costs. In a study comparing spending on schizophrenia medications, step therapy saved $19.62 per-member per -month in atypical antipsychotic expenditures. However, these savings were “accompanied by a $31.59 per-member per-month increase in expenditures for outpatient services.”2 As a result, step therapy increased health care costs.3 Similar findings have been observed when step therapy was applied to blood pressure medications.4

Step therapy can prevent Virginians from receiving treatment at all. In fact, studies have shown this to be true for one in five patients.5-7

How can we make step therapy better for Virginians?

Virginia needs to make it possible for patients to quickly obtain exceptions to step therapy if their doctor determines that going through step therapy could threaten their health. Putting such a clear and fair limit on step therapy would actually help control system-wide health care costs helping Virginians obtain the therapies that keep them stable and out of the hospital.

2. Farley, J. et al., “Retrospective assessment of Medicaid step-therapy prior authorization policy for atypical antipsychotic medications,” Clinical Therapeutics, 30: 1524-1539, 2008.
2. Mark, T. et al., “The Effects of Antihypertensive Step-Therapy Protocols on Pharmaceutical and Medical Utilization and Expenditures,” American Journal of Managed Care, 15: 123-131, 2009.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2949902/
2. Cox ER et al. “Health plan member experience with point-of-service prescription step-therapy,” J Manag Care Pharm. 2004;10(4):291-98.
5. Clinical and financial outcomes associated with proton pump inhibitors prior-authorization program in a Medicaid population,” Am J Manag Care. 2005;11(1):29-36.
6. Motheral B.R. “Pharmaceutical Step-Therapy Interventions: A Critical Review of the Literature,” J Manag Care Pharm. 2011;17(2):143-55.
7. Yokohama K et al. “Effects of step-therapy program for angiotensin receptor blockers on antihypertensive medication utilization patterns and cost of drug therapy,” J Manag Care Pharm. 2007;13(3)235-44.