Step Rx Therapy

To protect patients from the harmful impact of Step Therapy policies, Ohio lawmakers should pass legislation that reforms this process.

Fast Facts:

  • Step therapy, also known as "Fail First", is a tool used by health plans to control an insurer's costs. Under step therapy rules, a patient is required to try one or more alternative prescription drugs, chosen by their health plan, before coverage is granted for the drug originally prescribed by a patient's health care provider.
  • Step therapy is applied to drugs treating a wide range of diseases and conditions including autoimmune diseases, psoriatic and rheumatoid arthritis, cancer, diabetes, multiple sclerosis, mental health, among others.
  • The use of step therapy has increased. In 2010, nearly 60% of commercial insurers were using step therapy. Fifty-four percent of plans reported using it for cancer drugs in 2012, up from 36% the previous year.
  • Step therapy has shown it can have a negative impact on patients, including delayed access to the most effective treatment, disease progression and significant burdens on health care providers and their patients, as well as increases in health care costs.
  • Patient and health care provider organizations in Ohio urge state lawmakers to pass legislation to establish basic safeguards from the harmful impact of step therapy. It will also allow health care providers and patients to make decisions based on the best treatment options and a patient's medical history and not health plan step therapy protocols, treatment options and a patient's medical history and characteristics.

Initiative will highlight problems caused by the insurance industry protocol

American Academy of Dermatology Association
American Association of Diabetes Educators
American College of Rheumatology
American College of Surgeons, Ohio Chapter
Academy of Medicine of Cleveland and Northeast Ohio
American Cancer Society Cancer Action Network
American Diabetes Association
American Lung Association, Ohio and Michigan
Arthritis Foundation, Ohio
Cincinnati Area Senior Services
Cancer Support Community, Greater Cincinnati-Northern KY and Central Ohio
Central Ohio Diabetes Association

Chi Eta Phi Sorority, Inc.
Coalition of State Rheumatology Organizations
Columbus Chapter Black Nurses Association
Crohn's & Colitis Foundation of America: national, Central Ohio, and Southwest Ohio
Diabetes Partnership of Cleveland
Leukemia & Lymphoma Society
Lupus Foundation of America, Greater Ohio
Mended Hearts of Central Ohio
Mental Health & Addiction Advocacy Coalition
Mental Health America of Franklin County
Myasthenia Gravis Foundation of America, Columbus Support Group
National Alliance on Mental Illness, Ohio
National Organization for Rare Diseases
National Kidney Foundation, Central Ohio
National Liver Foundation, Heartland Division
National Multiple Sclerosis Society
National Patient Advocate Foundation
National Psoriasis Foundation
Ohio Osteopathic Association
Ohio Academy of Family Physicians
Ohio Asian American Health Coalition
Ohio Association of County Behavioral Health Authorities
Ohio Association of Rheumatology
Ohio Bleeding Disorders Council
Ohio Dermatological Association
Ohio Federation for Health Equity and Social Justice
Ohio Foot and Ankle Medical Association
Ohio Hematology Oncology Society
Ohio Pharmacist Association
Ohio Psychiatric Physicians Association
Ohio Sickle Cell and Health Association
Ohio State Medical Association
Prescription Assistance Network of Stark County, Inc.
Prevent Blindness Ohio
The Epilepsy Association (serving northeast Ohio)
The Ohio Council of Behavioral Health & Family Services Providers
U.S. Pain Foundation

Highlights of Ohio Legislation

  • Ensures step therapy protocols are based on clinical guidelines and not solely cost to the health plan.
  • Provides for a transparent exceptions and appeals process for prescribing health care providers & patients.
  • All requests and appeals must be determined within seventy-two hours for non-emergency and twenty-four hours for emergency cases.
  • Establishes circumstances for the prescribing health care provider to override step therapy when medically appropriate for a patient.

What Ohio Legislation Does Not Do

  • It does not prevent health plans from using step therapy nor limit the number of allowed steps.
  • It does not require health plans to develop a new exceptions process.
  • It does not prevent health plans from requiring prior authorization before covering a drug.
  • It does not prevent insurers from requiring patients to try a generic drug if it is equivalent to a brand.

Representatives from more than 45 patient and provider groups across Ohio have declared this month “Fail First February” in an effort to raise awareness of the insurance industry practice known as “fail first” or “step therapy”.   The “Ohio Coalition to Reform Step Therapy” is comprised of patient groups, physician organizations and pharmacists.

Step therapy is a cost savings tool used by health insurers that forces patients to take and fail on medications other than what their doctor has prescribed, before their insurer will cover the cost of the original medication

Step therapy protocols can be harmful to patients both financially and physically, causing an undue wait for the proper treatment and in some cases a worsening of a person’s medical condition.  Step therapy does not take into account an individual’s medical history or other factors, but instead relies upon a pre-determined prescription drug formulary or protocol.

“Step therapy undermines what doctors think is the best treatment for patients,” said Sarah Sams, MD. FAAFP, past president of the Ohio Academy of Family Physicians and current faculty at Grant Family Medicine residency.  “Physicians prescribe medications based on their knowledge of the patient’s overall health and ability to tolerate certain medications.  Physicians are finding step therapy is used increasingly, and even for generic medications. In addition, physicians are being asked to change medications that patients have been using for many years in order to try a different drug that is in the step algorithm.”

Legislation is currently underway in Ohio, to reform step therapy protocols.  Soon to be re-introduced from last session, the bills will give doctors a transparent and standardized process to appeal step therapy requirements for patients needing a particular treatment.   The bill does not ban step therapy, or the number of steps an insurer can implement.  Patients may still need a prior authorization from their insurers.  Senator Peggy Lehner (R-Kettering) will lead legislation in the Ohio Senate and Rep. Terry Johnson (R-McDermott) will lead companion legislation in the Ohio House.

“It is my great hope that we can raise awareness of the potentially dangerous practice of ‘fail first’ protocols’,” said Kenton Beachy, Executive Director of Mental Health America of Franklin County. “People with psychiatric disorders need to have access to the medications their doctors believe are the most appropriate for them. Improper use of medication can lead to negative and expensive outcomes such as emergency room visits, hospitalizations, possible entry into the criminal justice system, and in the most tragic examples, even death.”

 More information about fail first/step therapy protocols and its impact on patients is available at and by using the hashtag #FailFirstFeb on Twitter and Facebook.