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50 State Network Advocate Brief: Fail First/Step Therapy

How can you help?

Currently, state governments across the country are holding hearings to debate the introduction, modification, or total removal of Fail First/Step Therapy policies in their state.

Through your grassroots advocacy as part of the 50 State Network— online and in-person — the Fail First message of poor outcomes, inefficiencies, and higher costs can be conveyed to:

  • State elected officials and staffers (legislators and governor)
  • State-level committees and committee staffers
  • State Insurance Commissioners
  • State Medicaid Directors
  • Conventional media (television, newspaper, radio, magazines)
  • Unconventional media (bloggers, Twitter, Facebook, Instagram, discussion boards)

With your help delivering the message that “Fail First Hurts” to these audiences, we can either halt the introduction or accelerate the removal of the policy in your state.

What is Fail First/Step Therapy?

Fail First policies — also known as Step Therapy — are often insurance practices which require the least expensive drug in any class to be prescribed to a patient first, even if a patient’s physician believes a different therapy is medically in the best interest for their condition. Sometimes the cheapest drug works and sometimes it doesn’t. Your physician should make this decision, not your health insurance company.

Why do insurance companies use Fail First/Step Therapy?

Fail First/Step Therapy policies are used by health insurers to control costs. However, they are time-consuming from a physician and patient standpoint and are more expensive from a direct and indirect out-of-pocket cost perspective. The practice denies patients the drugs they need when they need them, and allows insurance companies to practice medicine without a license. And, while fail first policies control costs, the savings do not result in lower premiums for you. Instead they produce higher profits for insurance companies.

Can Fail First/Step Therapy harm patients?

Yes, these policies have already hurt patients severely in some states. If we do not speak out against the practice, Fail First/Step Therapy will continue to impact patients by:

  • Creating additional barriers leading people to forgo needed medications
  • Causing patients’ medical conditions to deteriorate, increasing the need for medical intervention in the future and raising the cost of health care
  • Increasing frustration and incidents of depression
  • Increasing the risk of non-compliance and self-medication