Insurers and pharmacy benefit managers (PBM) use a number of approaches to cut costs, including step therapy. Step therapy policies, which are also referred to as “fail first,” require individuals to try and fail on less expensive treatments, sometimes with adverse effects, before the insurer or PBM will cover the treatment prescribed to them. In theory, individuals are supposed to begin with the safest and most cost-effective treatment and then progress to riskier and costlier treatments. In reality, step therapy policies are unethical and inconsistent with standards of care, resulting in interference with the practitioner-patient relationship and significant delays in access to prescribed treatments.
States have introduced legislation to align the step-therapy process with clinical standards of care and allow for exemptions when step therapy would be inappropriate. Please click on the map below for state-specific information on legislation introduced this session.