Step Therapy

Step therapy (sometimes called "fail first") is a policy your insurance company may use that requires you to try one or more lower-cost medications before they'll cover a more expensive drug your doctor prescribed. The idea is to start with the most cost-effective treatment and "step up" to costlier options only if the first-line drugs don't work.

For example, if your doctor prescribes a brand-name medication for high blood pressure, your plan might require you to first try a generic alternative. Only if the generic doesn't control your blood pressure, or causes side effects, would the plan approve coverage for the brand-name drug.

Step therapy is used by most health plans as a way to manage drug costs. While it can sometimes save money without affecting care quality, it can also delay access to the medication your doctor believes is the best choice for your specific situation.

If step therapy creates a problem for you (like if you've already tried and failed the required first-step drug in the past, or if your condition is too serious to wait) your doctor can request an exception. This is typically done through a prior authorization process. Your doctor explains why the standard step therapy protocol shouldn't apply, and the insurer reviews the request.

You have the right to appeal if a step therapy requirement delays or denies access to a medication you need. Some states have enacted step therapy reform laws that require insurers to grant exceptions in specific situations, like when the first-step drug could cause harm.