What is Rx Step Therapy?

Rx Step Therapy, also known as "fail-first" therapy, is a prescription drug utilization management strategy used by health insurance plans and pharmacy benefit managers (PBMs). It requires patients to try and fail on one or more preferred, lower-cost medications before they can access coverage for a more expensive or non-preferred drug prescribed by their healthcare provider. Step therapy is often used for medications treating common medical conditions like chronic diseases or mental health disorders, where multiple treatment options are available.

Here's how it typically works:

1. Prescription Requirement: When a healthcare provider prescribes a medication, the patient's insurance plan reviews the prescription.
2. Preferred Drug First: If there is a preferred, lower-cost drug available for the condition, the patient is required to try it first. This is often a generic or less expensive brand-name drug with a proven track record for treating the condition.
3. Failure to Improve: If the initial medication does not effectively manage the patient's condition or causes intolerable side effects, the healthcare provider may request a step therapy exception from the insurance plan.
4. Step Therapy Exception: The healthcare provider submits documentation explaining why the patient requires the non-preferred medication immediately, bypassing the step therapy process.
5. Approval or Denial: The insurance plan reviews the exception request and can either approve the use of the non-preferred drug or deny it. Approval is usually granted when the lower-cost drug is ineffective or causes adverse reactions.

Rx Step Therapy aims to control prescription drug costs by encouraging the use of cost-effective medications when appropriate. However, it can be a source of frustration for patients and healthcare providers when they believe that the initially preferred drug is not the best choice for the patient's specific medical needs. The process of obtaining an exception can be time-consuming and may delay access to necessary medications. Nevertheless, it remains a common cost-saving strategy in healthcare benefit plans.

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