Avalere assessed potential implications of step therapy on patients with employer coverage to examine total OOP and payer costs. Step therapy—also known as “fail first”—is a common form of utilization management that health plans use to control costs. Step therapy requires patients to try a preferred drug before gaining access to the drug prescribed by their provider.
In some instances, step therapy may provide patients with an effective generic or low-cost treatment option and can therefore be associated with lower patient OOP and insurer costs. In other instances, step therapy may require patients to try a preferred brand option due to considerations related to contracts and rebate negotiations. In those instances, step therapy could serve as an obstacle to getting the product that a provider has deemed most appropriate for their patient and may be associated with delayed treatment, poor patient adherence, or a negative clinical outcome that may cause increased overall costs. Read More >>