Step therapy, also known as “fail first,” is a process used by health insurers to control costs. It requires patients to try one or more medications specified by the insurance company, typically a generic or lower cost medicine, to treat a health condition. Patients must then fail on the medication(s) before allowing a “step up” to another medicine that may be more expensive for the insurer.
Recommended medications vary for each patient as the biology of each person is different, so step therapy may place medications that are best for the patient out of reach. For example, two people with the same chronic condition may experience different levels of benefit or different side effects from the same drug. This is because their individual biological makeup responds differently to the ingredients of each drug.
When you and your doctor believe a prescription that does not follow your health plan’s step therapy process is the best choice for you, you will need prior authorization. Prior authorization is approval that your physician gets from your insurer verifying that a prescription drug is medically necessary for you. The approval is generally based on several factors, including a prior failure with another prescription, adverse events to the recommended medication or other special considerations.