Step therapy

Step therapy is a type of prior authorization used in managed care to control the costs and use of medications by patients. This is done by encouraging the use of less expensive alternatives. It is controversial, as it can delay treatment, and can contribute to patient noncompliance.

Overview

Step therapy is a practice used by insurance companies and third-party administrators that requires a patient to try one or more drugs before coverage is provided for a drug that was originally prescribed. This is done to control costs and steer patients towards less expensive drugs.

Process

The process of step therapy begins with the prescribing of a medication by a healthcare provider. The prescription is then sent to the pharmacy, where it is reviewed by the insurance company or third-party administrator. If the prescribed medication is not on the approved list, the patient is required to try a less expensive alternative first. If the alternative is not effective, the patient can then be approved for the originally prescribed medication.

Controversy

Step therapy has been controversial due to concerns about patient safety and the potential for delayed treatment. Critics argue that it can lead to noncompliance, as patients may not take the alternative medication if they believe it to be less effective. There are also concerns about the potential for increased healthcare costs due to the need for additional doctor visits and potential hospitalizations if the alternative medication is not effective.

Legislation

Several states have passed legislation to regulate the use of step therapy. These laws typically require insurance companies to provide a clear process for healthcare providers to request exceptions to step therapy protocols. They also often require insurance companies to respond to these requests within a certain timeframe.

See also

• Prior authorization
• Managed care
• Insurance companies
• Third-party administrators