Step therapy
Step therapy is a payer requirement that a patient try a preferred, usually lower-cost treatment first, and have it prove inadequate, before a more expensive alternative is covered.
Updated
Step therapy (sometimes called a fail-first or step protocol) is a coverage rule under which a payer will not cover a particular treatment — most commonly a medication — until the patient has first tried one or more preferred alternatives and those have proved ineffective or intolerable. It is a form of utilization management applied through the plan's coverage criteria.
It is closely related to prior authorization: satisfying a step-therapy requirement, or qualifying for an exception to it, is often what a prior authorization request has to demonstrate for the non-preferred treatment.
In practice
Plans generally provide an exceptions process for cases where the required first-line option is medically inappropriate — for example, where it is contraindicated or has already failed. Which treatments are subject to step therapy, what counts as an adequate trial, and how exceptions are requested are set by each payer and plan and change over time, so the governing rules are the ones in the plan's current policy. Documentation of the prior trials or the reason an exception applies is what supports the request.
Commonly confused with
- Prior authorization: Prior authorization is advance approval of a specific service; step therapy is a coverage condition that a request for a non-preferred option often has to satisfy.
- Formulary: A formulary lists which drugs a plan covers and on what terms; step therapy is one of the utilization rules a formulary can attach to a drug.