The concept is simple enough and eminently logical from an insurer’s perspective. It’s called “step therapy,” and it works as follows, illustrated through a representative scenario.
Say that you’re a patient with a serious condition that responds well to one particular medication. You are summarily informed by your insurance provider that your doctor-recommended drug is comparatively new and experimental and can be substituted for by an older and cheaper alternative.
The insurer gives you a use-it-or-lose-it ultimatum: Use the substitute or, alternatively, forgo your medication altogether.
Insurers routinely defend step therapy as a rational measure that ensures patients take proven medicines that are simultaneously cost-effective. They argue that the practice makes coverage more affordable for all insureds. If the established medicine doesn’t work, the former medication might be allowed once again.
Those most affected harbor a competing viewpoint, of course. Patients suddenly denied medicines that have unquestionably been working point to obvious health risks. Moreover, many of them stress that only one legitimate rationale underlies insurers’ step-therapy insistence, namely, a narrow focus on profit margins.
We have spotlighted step therapy previously at Mansell, Engel & Cole, chronicling the process in a January 23 blog post from last year. We noted therein widespread criticism that the practice “delays necessary treatment, undermines a doctor’s professional judgment, and actually ratchets up costs in most instances.”
Legislators in many states have responded to step therapy by passing laws that impose restrictions on it. Notably, Oklahoma has now followed that lead, with Gov. Kevin Stitt signing a bill earlier this year that limits the practice.
Questions or concerns regarding an insurer’s step therapy-linked actions, or any other issues tied to insurance delay or denial, can be referred to a proven pro-policyholders’ insurance law legal team.
