Step Therapy: Why Fail First for Everyone is Not a Good Idea

The Doctor Weighs In
6 min readJul 23, 2019

By: Corey Greenblatt

Physicians may endorse step therapy for medical reasons but when it is used solely to save the system money, it can harm people with chronic illnesses.

Photo source: iStock

The final rule that would allow Part B Medicare Advantage health plans to implement step therapy and other drug-limiting programs was announced by the Center for Medicare & Medicaid Services (CMS) on May 16, 2019. You can read about it this press release entitled “CMS empowers patients with more choices and takes action to lower drug price.” This rule is part of the Trump Administration’s plan to lower drug prices by introducing more negotiation and competition.

The problem is that these “fail first” programs will adversely affect people with arthritis and other chronic illnesses. Here’s why.

What are Part B medications?

Part B medications are treatments that need to be administered in a provider’s office or in a hospital setting. Patients with rheumatoid arthritis and other autoimmune diseases, as well as many other chronic disorders, are often forced to use medications covered under Medicare Part B. This is because of the complexity and progression of their disease on other types of treatments.

It should be clear, therefore, that policies like this have the effect of targeting people with chronic diseases.

The initial proposed rule described in the press release (above) had many patient organizations worried, including the Global Healthy Living Foundation (GHLF). However, the final rule appears to have taken public comments into consideration.

It implements a number of safeguards that patient groups can support. This is because these new components of the regulation seem to ensure that these programs are put in place with the patient at the center of all discussions.

Let’s dive into some of the ways in which these safeguards may accomplish that.

Don’t fail first, succeed first

Step therapy, or “fail-first”, protocols are a one-size-fits-all cost-saving practice that requires patients to try and fail on one or more prescription drugs before accessing the more…

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