“Step” therapy

How it may impact your patients and your practice

It is now fairly common for an insurance plan to have significantly different coverages for different but similar medications, such as intravitreal injections. It’s hard for us to know what the exact benefit is in advance — while one patient can have a low (or no) co-pay another patient has a high co-pay for the same medicine.

Adding to this administrative challenge are insurance company efforts to control costs. One such method of control is to implement what is now referred to as “step” therapy in which the plan would require providers to first use the less-costly alternative. Step therapy is also sometimes referred to as “fail-first” therapy, because you have to prove failure with one drug before moving to another

Step therapy, documentation, and communication

Medicare has released guidance that will allow Medicare Advantage (Part C Medicare) plans to implement “step” therapy starting in 2020; some commercial plans have already begun to do this. Will a step therapy approach mean that everyone has to use the lowest cost drug? Of course not. In some situations, “fail-first” notion just does not make good clinical sense because it won’t be good care — and in that situation you may be communicating with the insurance company to get the patient what they need.

Your chart documentation is the key to winning the insurance’s support to approve that more expensive drug. Listen to your provider, and chart the reasons why the other drug can’t be used.

Three of the most common reasons to not start or keep using this insurance-mandated drug are:

  • The patient has already tried the other alternative and is on the expensive drug now — but was on another insurance plan in the past. (This insurance has no idea that is the case.) It should be a simple matter to get the current plan on board if the chart has the proper information.
  • The patient is allergic to one or more of the components in the “fail-first” drug the plan wants you to use (using that drug would cause the patient harm). Again, having the information in the chart is key to winning the insurance’s support for the change to the pricier option as the first choice by the doctor.
  • Even though the doctor tries the “fail-first” drug, the patient does not respond like anticipated and other options need to be tried.


Know that if a certain drug plan requires more information before approving an intravitreal drug or eye drop, we can help gather it and submit it to the insurance with our doctors’ blessing. Realize that insurance plans might have “step” or “fail-first” protocols in place before more expensive options can be considered. Ultimately, you must be an advocate for your patients and providers!

As always, “good coding to you.” OP