Have you ever tried to fill a prescription from your doctor only to have your pharmacist tell you that your insurance won’t cover it because of something called, “step therapy?” What is this step therapy and why should your insurance company be able to dictate what medication your doctor can prescribe you?
Step therapy is a process used by insurance companies to ensure patients are being prescribed medically necessary drugs in a step-wise fashion. The order of treatment usually has been predetermined by a well-established medical association or society, like the National Heart, Lung, and Blood Institutes’ “Guidelines for the Diagnosis and Management of Asthma.”
The medical associations and societies invest time and research into developing these peer-reviewed guidelines, so they are usually considered the standard of care for a specific medical condition. There is a reason certain medications are considered “first-line” treatments – they have been proven to be the most effective and safe in a majority of patients through various clinical trials and studies. If a patient doesn’t get complete symptom resolution or has severe side effects, then the doctor will progress to the secondary tier of treatment, and so on.
Insurance companies can then use these guidelines to base their own standards for payment. From a patient care and a business point of view it makes sense to encourage doctors to prescribe “first-line” treatments initially. Unless there is some mitigating factor, like a serious allergy, you most likely will have the best chance at complete recovery when you try the “first-line” drug.
What insurance companies are trying to discourage is doctors prescribing expensive, unnecessary medications that have questionable benefit. In order to ensure you really are not receiving the expected benefit from a drug, you will have to be on it for a trial period of some length, depending on how long it takes for the drug to work and show the maximum benefit – usually anywhere from a few weeks to a few months.
During this time, you should feel free to monitor your symptoms and possibly keep a journal to track any improvements or even declines. At your follow up appointment with your doctor, you can then discuss your progress (or lack of it) and whether you need to switch to a second-tier drug.
While you (and possibly your doctor) may have entered this whole process with a specific super expensive, brand name, fifth-tier medication in mind as the cure-all, remember that there is a reason for the step therapy process and that it generally works. It might turn out to be the case that you have to try dozens of ineffective medications before you finally find your silver bullet, but you also may be surprised by one you’d prematurely crossed off the list in your mind.
Bottom line, step therapy can sometimes seem frustrating and tedious, but there’s a reason insurance companies still use it – it works.