Trends In Step Therapy: Is It Getting Better or Worse?!

Trends in Step Therapy: Is It Getting Better or Worse?

By Brianna Pepin

 Let’s be real—step therapy has always been one of the biggest headaches in the world of biologics. Whether it’s a brand-new patient or someone doing well on their current treatment, it can feel like insurers are constantly telling us, “Try this cheaper option first, even if it’s not what your provider recommends.” 

So where are we now? Are things improving with legislation and advocacy—or are we still stuck playing insurance games? Let’s talk about what we’re seeing, what’s changing, and what to do when patients get caught in the middle. 

 What Is Step Therapy—And Why Does It Matter? 

Step therapy, sometimes called “fail first,” is when an insurance plan requires a patient to try (and fail) one or more lower-cost medications before covering the one originally prescribed. In theory, it’s about cost containment. But in reality? It delays appropriate treatment, increases disease burden, and puts patients and providers in a frustrating loop of appeals and justifications.  Are Things Getting Better? Yes—and no. 

There’s been some movement in the right direction, but progress is inconsistent and often depends on where you live and who your patient’s insurance carrier is.

 ✅ Where We’re Seeing Improvement: 

State legislation is growing. As of now, over 30 states have passed laws that put some guardrails on step therapy—like requiring exceptions or timelines for appeals. Some payers are loosening up. Certain insurers are starting to recognize when a patient has already failed other treatments in the past (especially if it’s documented well). Advocacy groups are getting louder. Groups like the National Psoriasis Foundation, Global Healthy Living Foundation, and AADA have been pushing back—and it’s working in some markets. 

🚫 But Here’s the Flip Side: Policies vary widely. A patient in Maine might have more protections than a patient in Texas, for example. Insurers are still using step therapy as a tool to cut costs—and not always in ways that align with clinical guidelines. Patients with stable disease are still at risk of being switched to something cheaper, even if they’re doing well. 

So… better? Yes, in some ways. But we’ve got a long way to go.  

What To Do When Patients Get Caught in the Middle Here’s how I typically approach it: 

1. Validate their frustration. It’s confusing, especially for someone who thinks, “But my provider said this was the right medication for me.” A simple, “I know this feels unfair, but I’m here to help you through it,” can go a long way. 

2. Explain what’s happening—in plain language. “Your insurance wants us to try a different medication first before they’ll approve the one your provider prescribed. We’re working on getting that changed.” 

3. Request a step therapy exception (if applicable). Most plans do have a medical exception process—use it! Document past failures, side effects, or why the preferred option is not medically appropriate. 

4. Use the provider's voice when needed. Letters of medical necessity, chart notes, and peer-to-peer reviews often carry more weight than appeals alone. Don’t hesitate to loop in the provider when you know it’ll make a difference. 

5. Stay on top of timelines. Each plan has different turnaround times. Set reminders to follow up so patients don’t get stuck waiting longer than necessary.  

What We Can Do as Biologic Coordinators Even though we’re not policymakers, we are powerful advocates. A few ways we can push back:

 Keep detailed documentation. Every delay, every denial, every flare—it’s data we can use. Get involved at the policy level. Even sending a letter to your state rep or sharing your professional perspective with an advocacy group helps move the needle. Educate the care team. When providers understand how to avoid common pitfalls in the step therapy process, everyone benefits.     

Step therapy isn’t going away any time soon. But with smart documentation, strong advocacy, and patient-centered communication, we can reduce the impact it has on our patients’ lives. 

And every time we push back successfully? We’re not just helping one patient—we’re laying the groundwork for better access for everyone down the line. 

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