Step Therapy (Fail First)
An insurance requirement that a patient must try and fail on one or more lower-cost drugs before the plan will cover a more expensive medication.
How It Works
Step therapy, also called "fail first," requires patients to demonstrate that cheaper alternatives don't work before the insurer will pay for the prescribed drug. For example, a patient with rheumatoid arthritis might need to try methotrexate before getting coverage for a biologic like Humira. Proponents say step therapy controls costs and ensures appropriate use. Critics argue it delays access to the most effective treatment and subjects patients to side effects from drugs their doctor didn't recommend. Many states have enacted step therapy reform, requiring exemptions for certain conditions.
Related Terms
- Prior Authorization — A requirement by an insurer that a patient's doctor must get approval before the plan will cover a specific drug — used to control costs and ensure appropriate use.
- Formulary — A list of prescription drugs covered by an insurance plan, organized into tiers that determine how much the patient pays for each drug.
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About This Definition
This definition is part of the DrugPrice Drug Pricing Glossary — 34 terms explaining how prescription drug pricing works in the United States. All definitions are written in plain language for patients, caregivers, journalists, and healthcare professionals.