Step Therapy

Hey everyone,

I recently had yet another poor experience with step therapy that left me feeling frustrated and helpless. As someone who relies on my doctor and my own knowledge to manage my pain, it’s disheartening to know that the drugs I need or would like to try to feel better are often not covered by insurance or require me to jump through hoops of flames before they can be prescribed.

step therapy needs to change.

If I am feeling this way what are people feeling that really need to get medication to have a semi functional and mobile life feeling like? People with cancer, sickle cell, rheumatoid arthritis,juvenile arthritis, diabetes etc….

Patients shouldn’t have to suffer or waste time trying out medications that don’t work for them. We deserve better. Why are health insurance companies trying to undermine our primary care physicians?

Step therapy’: a serious, unnecessary barrier to patients getting appropriate treatment
It’s heartbreaking — and frankly, morally wrong — when you see a patient with hope that they might get some relief from their symptoms only to be told they can’t have the appropriate treatment.

If you are not sure what it is – here is a breakdown

What is step therapy?

If a health plan uses step therapy for certain drugs, it means that a patient can be required to try a lower cost prescription drug that treats a given condition before “stepping up” to a similar-acting, but more expensive drug. The health plan won’t cover the more expensive drug until the lower-cost medication has failed to treat the patient’s condition. Other names for step therapy are “step protocol” and “fail first requirements.”

Step therapy is a very common cost-control strategy. Their claim

Step therapy generally saves money for both the patient and the health plan.

The clinical basis for step therapy is that some conditions can be treated with different but therapeutically equivalent medications and there is not a good way to predict if a particular medication will be more or less effective for any one individual.

In those cases, it is more cost-effective to start with a “step 1” drug – a generic drugor lower-cost or preferred brand-name drug – before trying a more expensive or non-preferred drug. Step 1 drugs are on a lower tier of a formulary, so the consumer pays a lower copay.

For the health plan, the base price (or ingredient cost) is typically lower for a low-tier vs. high-tier drug. Drug tiering and preferred/non-preferred status can also depend on the rebates that the health plan’s pharmacy benefits manager receives from the drug manufacturer. 

Step therapy can be disruptive when a consumer moves from one insurer to another. A consumer might have tried one or more step 1 therapies under one health plan only to move to another health plan that requires the consumer to start over – or has different classifications of step 1 and step 2 medications. In these cases, your doctor may need to work with your new insurance plan to get a prior authorization (also called a step therapy exception or coverage determination) to continue coverage for the drug therapy that has been working well for you.

The Importance of Step Therapy Reform for Arthritis Patients

Arthritis is a debilitating disease that affects millions of people around the world. It causes inflammation and stiffness in the joints, leading to pain and limited mobility. While newer therapies have been developed in recent years to manage this condition, some patients still struggle to access the necessary treatment due to step therapy.

Step therapy requires patients to try and fail on several less expensive or generic medications before they can access higher-cost, potentially more effective treatments. This approach is aimed at reducing healthcare costs, but it can negatively impact the health of patients with arthritis. Delaying access to the right medication can result in significant joint damage, deformities, surgeries, and disability.

Fortunately, there is hope for change. Across the nation, advocates have been pushing for step therapy reform legislation, and Minnesota is no exception. Representative Kelly Fenton and Senator Paul Utke have proposed bills (SF 2897/HF 3196) to make step therapy a more patient-focused process. While these reforms do not eliminate step therapy, they aim to make it more workable and accessible.

More than a dozen states have already passed similar laws, recognizing the importance of putting patients first. It is time for Minnesota lawmakers to follow suit and prioritize the health and wellbeing of their constituents. Every patient deserves access to the best possible care without unnecessary barriers.

Step therapy reform is crucial for Arthritis patients, and we must act now to ensure that everyone has access to the right treatment. Lawmakers in Minnesota must take notice and pass the necessary legislation to improve the lives of those who are suffering from this debilitating condition. It’s time to put patients first and eliminate unnecessary barriers to good care.

Let’s work together to make a change and ensure that patients like us get the care we need and deserve. Share your story and let’s raise our voices! #endsteptherapy #healthcareforall #patientrights


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