What to Know: Fail First/ Step Therapy

What is Fail First/Step Therapy?
Fail First policies — also known as Step Therapy — are often insurance practices which require the least expensive drug in any class to be prescribed to a patient first, even if a patient’s physician believes a different therapy is medically in the best interest for their condition. Sometimes the cheapest drug works and sometimes it doesn’t. Your physician should make this decision, not your health insurance company.

Why do insurance companies use Fail First/Step Therapy?
Fail First/Step Therapy policies are used by health insurers to control costs. However, they are time-consuming from a physician and patient standpoint and are more expensive from a direct and indirect out-of-pocket cost perspective. The practice denies patients the drugs they need when they need them, and allows insurance companies to practice medicine without a license. And, while fail first policies control costs, the savings do not result in lower premiums for you. Instead they produce higher profits for insurance companies.

Can Fail First/Step Therapy harm patients?
Yes, these policies have already hurt patients severely in some states. If we do not speak out against the practice, Fail First/Step Therapy will continue to impact patients by:

  • Creating additional barriers leading people to forgo needed medications
  • Causing patients’ medical conditions to deteriorate, increasing the need for medical intervention in the future and raising the cost of health care
  • Increasing frustration and incidents of depression
  • Increasing the risk of non-compliance and self-medication


What to Say: Fail First/ Step Therapy

  1. When a patient has to fail first on a drug before being allowed to take the medication originally prescribed, the patient, physician and public health suffers.
  2. Fail first policies intrude on the patient/physician relationship and lead to:
    1. Prolonged illness
    2. Unstabilized care and the potential for permanent damage to occur
    3. Higher overall healthcare costs
    4. Increasing lost productivity
    5. Reduction in patient quality of life
    6. Forcing patients to sometimes take drugs that are not FDA approved for their condition