Step Therapy/Fail First: What's Your Experience?  

Step Therapy is a process employed by health insurance providers requiring patients to first take alternate medications before the physician- recommended medication is approved for reimbursement or coverage. There is a debate on whether this process is cost-effective for patients or more of a cost-saving measure for insurers.

In lupus, as with many other chronic illnesses, patients are often prescribed expensive medication to deal with a myriad of symptoms. Since no two patients are exactly alike, medications that work for one patient may not be as effective for another, and medical providers are constantly striving to match the right medication with their patients' specific conditions and health status. Unfortunately at times, the more effective treatment or drugs are those that are also more cost-prohibitive.  

For patients with a good health plan coverage, getting approved for these more expensive medications may not be such a challenge. But what if one's health insurance provider has a rigid policy on Step Therapy, requiring that a patient must first fail with less-costly drugs before getting approved for coverage of more expensive, albeit effective medication?

As a case in point, the new lupus drug Benlysta would cost an average of $35,000 a year for each patient. What would it take - and how long -before a health insurance company approves this drug for a patient, assuming that the attending physician determines it is the best hope for the patient's lupus treatment?

Step Therapy is among the topics for discussion at LFNC's Spring Lupus Mini-Conference scheduled on April 28, 2012 at Kaiser Permanente in Redwood City.

Do you have personal experiences with Step Therapy? Are you being forced to take less-costly medications that may not be as effective for treatment because it is a pre-requisite to coverage of more expensive yet more effective drugs as determined by your doctor? We invite you to share your thoughts and experiences to help inform our advocacy efforts for better health care access for lupus patients. Email us.

BREAKING NEWS!! California Assemblymember Jared Huffman has introduced a bill- AB 369 - that prohibits a health plan from requiring a subscriber to try and fail on more than two medications before allowing the patient to have the medication prescribed by his or her doctor. Read MORE.