Doctors Oppose Step Therapy's Effect on Patients

Insurance companies and pharmacy benefit managers use step-therapy policies to require doctors to prescribe older, less expensive drugs first, which patients must fail to respond to adequately before they become eligible for newer, more expensive treatments.
Jackie Syrop
October 10, 2017

According to one insurer, before a biosimilar can be reimbursed, a patient has to have tried the brand-name anti-TNF agent for at least 14 weeks, and the physician must attest that either the patients’ clinical response would be expected to be superior with a biosimilar, or the patient in question has a history of intolerance or an adverse event related to the brand-name anti-TNF agent (and the physician must attest that the same intolerance or adverse event would not be expected with the biosimilar).

“The notion that a physician should ever attempt treatment with a biosimilar of its original drug that has already failed to treat the patient’s symptoms is nonsensical, as by definition there are no significant differences between the biosimilar and the original drug,” Popovian and Azoulay note. “Patients deserve unobstructed access to the treatments they need, not to have their health outcomes determined by contractual restrictions designed to avoid competition.”
Research suggests that step therapy, while often shown to reduce the costs involved with covering prescription drugs, can result in unintended consequences. For example, step therapy protocols used for Medicaid patients with bipolar disorder in Maine resulted in a “trivial” cost reduction for certain drugs; savings were found to be due in large part to the fact that patients stopping taking their medications as opposed to having switched to cheaper alternatives.


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