Living with Chronic Pain

Understanding Step Therapy

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Step therapy, also known as "fail first,” is a process used by insurance companies in which an individual must first treat their medical condition with a less expensive medication (that has been proven effective for people with the same condition) before they can “step-up” to a more costly prescription. Usually, this entails trying generic versions of a medication before the brand-name medication will be covered.

Step therapy is used by all major private insurance companies for the sole purpose of cost effectiveness. An individual who is not obtaining the desired result with the less expensive drug would then become eligible for coverage of a more expensive medication (a "step-up" medication). Most of the medications on the top level of step-therapy drug lists are new medications, very expensive therapy types or expensive formulations of common drugs, such as extended-release formulas.

The increase of prescription drug prices in the U.S. has added to the stress of health care providers to keep the cost of prescriptions reasonable for individuals in their care while also maintaining the highest level of care possible. Individuals may appeal insurance coverage denials for certain medications due to the step-therapy process. Physicians and individuals alike are encouraged to become educated on step-therapy so that they can have a voice in medication treatment.

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