Sorry, you need to enable JavaScript to visit this website.
Skip to main content
Home

Header Top Menu

  • Careers
  • Investors
  • News
    • Press Release Archive
    • Press Statements
    • Podcasts
      • The Antigen Podcast
      • Get Science Podcast
      • Diverse Perspectives Podcast
      • menopause: unmuted
      • Hemcast
    • Contact Media Relations
    • Press Kits & Downloads
      • Company Press Kit
      • Pfizer Oncology Press Kit
      • PSA Narrative
      • RA NarRAtive
      • Rare Disease Gene Therapy Press Kit
      • ATTR-Amyloidosis Press Kit
      • UC Narrative
      • Eczema Inside Out Press Kit
  • Partners
    • Discovery to Pre-candidate
      • Focus Areas
        • Therapeutic Areas
          • Internal Medicine
          • Inflammation and Immunology
          • Oncology
          • Rare Disease
          • Vaccines
        • Therapeutic Modalities and Technology Platforms
          • Drug Safety
          • Gene Therapy
          • Target Sciences
          • Precision Medicine
          • Medicinal Sciences
            • Biologics Product & Process Development
            • Biotherapeutics Discovery
            • Medicine Design
            • Small Molecule Product & Process Development
        • Emerging Science
          • DNA Damage Response
          • Microsatellite Repeat Expansions
          • Senescence
      • Partnering Models
    • Candidate Through Commercialization
      • Focus Areas
        • Internal Medicine
        • Inflammation and Immunology
        • Oncology
        • Rare Disease
        • Vaccines
        • Hospital
    • Pfizer CentreOne
    • Pfizer Ventures
      • Our portfolio

Healthcare Professionals

  • Healthcare Professionals

Connect with Us

  • Connect with Us
    • Email
    • FAQ
    • Privacy Policy (NEW)
    • YouTube
    • Twitter
    • Facebook
    • LinkedIn
    • Instagram
  • Your Health

    • Healthy Living
      • Brain & Nervous System
      • Cardiovascular Health
      • Cold & Flu
      • Digestive Health
      • Healthier Aging
      • Living Tobacco Free
      • Men’s Health
      • Mental Health
      • Nutrition & Fitness
      • Pediatric Health
      • Respiratory Health
      • Skin Health
      • Vaccines & Prevention
      • Women’s Health

    • Disease & Condition
      • Cancer
      • Cardiovascular Diseases & Conditions
      • Diabetes & Metabolic Disorders
      • Immune System Diseases & Conditions
      • Infections & Infectious Diseases
      • Neurological Diseases & Conditions
      • Menopause
      • Rare Disease
      • Vaccine-Related Conditions
      • Skin Diseases & Conditions
      • Atopic Dermatitis
      • Cardiovascular Disease
      • Severe Hypertriglyceridemia

    • Coronavirus disease (COVID-19) Resources

    • Managing your health
      • Caregiving
      • Evaluating Health Information
      • Tracking Your Health
      • Your Medicines
      • Health Literacy

    • Wellness
    Hot Topics

    Maintaining Emotional Well-Being During COVID-19

    Emotional Well-Being Tips for People Living with Chronic Inflammatory Conditions During COVID-19
  • Our Science

    • Driven to Discover the cure

    • Focus Areas
      • Internal Medicine
      • Inflammation & Immunology
      • Oncology
      • Rare Disease
      • Vaccines
      • Anti Infectives

    • Product Pipeline

    • Clinical Trials
      • Guide to Clinical Trials
      • Find a Trial
      • Expanded Access & Compassionate Use
      • Clinical Trials in Children
      • Partnering with Pfizer
      • Trial Data & Results
      • Research Integrity & Transparency
      • Diversity in Clinical Trials

    • R&D Platforms
      • Biosimilars
      • Gene Therapy
      • Medicinal Sciences
      • Precision Medicine
      • Maternal Immunization

    • Collaboration
      • Partner with Pfizer

    • Research sites

    • Coronavirus disease (COVID-19) Resources
      • All COVID-19 Updates
      • Vaccine Efforts
      • Antiviral Efforts
      • Partnerships & Anti-Infective Efforts
      • Supporting the Fight Against COVID-19
    HOT TOPICS

    MRNA VS. CONVENTIONAL VACCINES

    What Makes an RNA Vaccine Different From a Conventional Vaccine?
  • Our People

    • Meet The Experts
      • Scientists
      • Internal Medicine – Metabolic Disease
      • Inflammation & Immunology
      • Oncology
      • Rare Disease
      • Vaccines
      • Medical Professionals

    • The Journey

    • Leadership
      • Executives
      • Board Members
      • Company Fact Sheet

    • Diverse Perspectives
      • Diversity & Inclusion
      • Supplier Diversity
    HOT TOPICS

    Meet our new Chief Patient Officer, Dr. Dara Richardson-Heron

    dr_richardson_300x170.jpg

    Working Together to Empower Women

    VizagWomen_300x170.jpg

    • Hot Topics
  • Our Purpose

    • Commitment to Global Health
      • Expanding Access
      • Strengthening Health Systems
      • Providing Disaster & Humanitarian Relief
      • Unleashing the Power of Our Colleagues
      • Highlighting Individual Voices

    • Protecting People and the Environment
      • Pfizer's Green Journey
      • Product Stewardship
      • EHS Governance
      • EHS Supply Chain
      • Key Performance Indicators
      • Health & Safety
      • Human Rights

    • Positions on Health Policies
      • Ready for Cures
      • How does Pfizer price medicines?
      • Value of Medicines
      • Policy Positions
      • Creating Cures Through Facility Investments

    • Transparency
      • Working with Health Care Professionals
      • Transparency in Grants
      • Code of Conduct
      • Corporate Compliance
      • Sales and Marketing Compliance

    • Independent Grants
      • Competitive Grants Program
      • Independent Medical Education
      • Investigator Sponsored Research
      • Quality Improvement
      • COVID-19 Vaccine Grants

    • Contributions & Partnerships
      • Healthcare Charitable Contributions
      • Lobbying & Political Contributions
    HOT TOPICS

    Pfizer Women’s Resource Group

    Media Name: IWD_Pull_up_Banner_300x170.jpg

    • Hot Topics
  • Our Products

    • Product listing

    • How drugs are made
      • Branded vs. Generic
      • Biologics & Biosimilars
      • Commitment to Quality

    • Distributors
      • Pfizer Distributors
      • Greenstone Distributors

    • Medicine Safety
      • Reporting Adverse Events
      • Making Good Treatment Choices
      • Partnering With Patients
      • Health Literacy
      • Medicine Safety Tips for Patients
      • Counterfeiting
      • Unused Medicines

    • Safety Data Sheets

    • Medical Information Contacts

    • Pfizer Global Supply
    HOT TOPICS

    Universal vs. Single Payer Healthcare

    Media Name: universal_healthcare300x170.jpg
  • Careers

    • Working Here
      • Mission & Purpose
      • Culture
      • Diversity & Inclusion
      • Career Growth & Colleague Development
      • Compensation & Benefits
      • Ensuring Corporate Responsibility
    • Search Jobs
    • Student & Early Career
      • Postdoctoral Program
      • US Summer Student Worker Program
      • Opportunities for Veterans
    • Pfizer365.com
    • Our Hiring & Recruiting Process
      • Frequently Asked Questions
      • Tips for Interviewing at Pfizer
    • Connect With Us
  • Investors

    • Investors Overview
      • Why Invest / Our Story
      • Prospective Investors
      • Fact Sheet
    • Events & Presentations
    • Financials
      • Quarterly Reports
      • Annual Reports
      • SEC Filings
      • Interactive Data Filings
    • Investor News
    • Stock Information
      • Historical Price Lookup
      • Investment Calculator
      • Historical Stock Chart & Data
      • Dividend & Split History
      • Stock FAQs
    • Governance
      • Board Committees and Charters
      • The Pfizer Board Policies
      • Corporate Governance FAQs
      • Contact Our Directors
    • Shareholder Services
      • Stock FAQs
      • Advisory Information
      • Cost Basis Calculator
  • News

    • Contact Media Relations
    • Podcasts
    • Press Kits & Downloads
    • Press Release Archive
    • Press Statements
  • Partners
  • Footer links

    • Footer Aside Section1
      • CAREER-SEEKERS
      • INVESTORS
      • News & Media
      • Partners
    • Footer Aside Section 2
      • Healthcare Professionals
      • Business To Business
      • Change Region
      • Sitemap
    • Footer Aside Section3
      • Twitter
      • Facebook
      • Linkedin
      • Instagram
      • Youtube
    • Footer Aside Section4
      • Contact Us
      • Terms of Use
      • Privacy Policy

What is Step Therapy and What Does It Mean for Patients?

What is Step Therapy and What Does It Mean for Patients?
OUR PURPOSE/ What is Step Therapy and What Does It Mean for Patients?
May 21, 2019

Medical doctors have years of training and expertise in their chosen field. And yet, when it comes to prescribing a medication, they often have to jump through hoops before their patients can get the medicine they recommended. One of those hoops is called a “fail first” or “step therapy” policy.

What is step therapy?

Step therapy is when an insurance company or pharmacy benefit manager (PBM) requires a patient to try certain medications, which may be lower cost to them, without success before agreeing to cover a particular medication that the patient’s doctor prescribed. In other words, the insurance company may deny a drug that a doctor has chosen to prescribe in an effort to control their costs.[1]

How does it work?

As an example, a physician prescribes a medication for a patient's condition. That medication is on the drug formulary, but the insurance company requires the patient to first try—and fail—medications the insurance company "prefers." When this happens, the physician must then prove to the insurance company or PBM that those drugs didn’t work in the past, in order for the patient to get coverage for the medication that the physician had originally prescribed.

The process can take weeks or even months. And if a patient switches to a new insurer, they may have to go through this process again, depending on the drug formulary and the insurance plan.

What does it mean for patients and physicians?

This practice can present challenges for patients, many of whom have serious illnesses and cannot afford to delay getting the treatments they need. In 2017, the American Medical Association surveyed 1,000 U.S. physicians about prior authorization—requiring a doctor to state that a drug is medically necessary for the patient—[2]and 92% indicated that prior authorization procedures can result in delays in care for patients as they go through the required steps.

15% of physicians said the process “always” results in delays to necessary care

39% said it “often” results in delays to necessary care

38% said it “sometimes” results in delays to necessary care

6% said it “rarely” results in delays to necessary care

1% said it “never” results in delays to necessary care

Further, the AMA survey found that the process can lead to patients abandoning treatment. 78% of physicians polled reported that they’d seen patients give up on the recommended course of action.[3]

Fail-first policies can also be burdensome to physicians. Eighty-four percent of those polled by the AMA said the burden was “high or extremely high” on physicians and staff in their practice.[4] And 51% noted that the burden has “increased significantly” in the past five years.[5]

In 2018, the AMA and nearly 100 medical groups opposed allowing Medicare Advantage plans to use step therapy for Part B drugs beginning in 2019, stating in a letter[6] that “delays in getting appropriate treatments can mean prolonged symptomatic periods and irreversible damage” for patients with particular diseases like UC, and for those with cancer, “selecting the proper personalized treatment as quickly as possible can be critical to survival.”

What can patients do?

A number of states are stepping up to make a difference. In recent years, 19 states have passed laws that allow insurers and PBMs to continue to use step therapy, but add important patient protections that ensure it is used safely and appropriately.[7] For example, some state laws ensure that patients can be exempted from step therapy requirements when medically appropriate. Some states also limit the amount of time that insurance companies or PBMs can wait before approving or denying an exemption request.

Patients can find out if their state has a policy that helps establish rules and limits for step therapy and educate themselves about what it covers. If their state doesn't have such a policy, they can reach out to elected officials and voice their support for responsible step therapy practices that put patients first.

Sources

[1]“The ethics of 'fail first': guidelines and practical scenarios for step therapy coverage policies” (second sentence), Health Affairs

[2]“2017 AMA Prior Authorization Survey,” American Medical Association (“care delays associated with PA”)

[3]“2017 AMA Prior Authorization Survey,” American Medical Association (“abandoned treatment associated with PA)

[4]“2017 AMA Prior Authorization Survey,” American Medical Association (“additional PA burden findings”)

[5]“2017 AMA Prior Authorization Survey,” American Medical Association (“change in burden over last five years”)

[6]“Letter to CMS on step therapy,” American College of Physicians online

[7]50-State Network

Show
Hide

Footer menu

  • Your Health
    • Healthy Living
    • Disease Conditions
    • Manage Your Health
  • Our Science
    • Therapeutic Areas
    • Product Pipeline
    • Clinical Trials
    • R&D Platforms
    • Collaboration
    • Research SItes
  • Our People
    • Meet the Experts
    • The Journey
    • Leadership
    • Diverse Perspectives
  • Our Purpose
    • Commitment To Global Health
    • Positions on Health Policies
    • Transparency
    • Contributions & Partnerships
  • Our Products
    • Product Listing
    • How Drugs are Made
    • Distributors
    • Global Product Information Contacts

Footer aside

  • Footer Aside Section1
    • CAREER-SEEKERS
    • INVESTORS
    • News & Media
    • Partners
  • Footer Aside Section 2
    • Healthcare Professionals
    • Business To Business
    • Change Region
    • Sitemap
  • Footer Aside Section3
    • Twitter
    • Facebook
    • Linkedin
    • Instagram
    • Youtube
  • Footer Aside Section4
    • Contact Us
    • Terms of Use
    • Privacy Policy
Pfizer Logo Footer

Copyright © 2002-2021 Pfizer Inc. All rights reserved. This information—including product information—is intended only for residents of the United States.
The products discussed herein may have different labeling in different countries.