Step Therapy Guardrails Benefit Patients Fairly

Step therapy, also known “fail first,” is the practice of insurance companies requiring a patient to try and fail one or more medications before allowing the patient to take the one their doctors originally prescribed. For those with psoriasis and psoriatic arthritis, there are many problems with this practice, including causing irreversible disease progression.

According to a 2020 National Psoriasis Foundation survey (NPF), 70 percent of patients in the psoriatic disease community have experienced step therapy for biologic medications. My son and I both have psoriasis and psoriatic arthritis, and while we haven’t directly experienced having to fail one medication first before receiving proper treatment, I do worry about step therapy if we switch insurance and when my son turns 26 and must get his own health insurance. In these cases, we may be forced to start back at the beginning – light therapy, creams, NSAIDs, methotrexate, and others before getting back on the biologic that has worked to keep our diseases in check for more than five years.

The NPF and its advocates virtually met with legislators and their staff on April 20-21, 2021 to ask for step therapy reform. I was honored to be among that group of volunteers.

The Safe Step Act

Step therapy reform is needed to make sure patients get their required medication in a safe and timely manner. Nearly 30 states have already passed some reform, but we also need reform at the federal level. This is a great first step, but we need more. Currently, state bills apply to state insurance plans, but we need federal laws to cover federal insurance plans. The bipartisan Safe Step Act aims to be that bridge state to federal laws.

Putting up guardrails

It is important to note that the Safe Step Act does not eliminate step therapy. Instead, it creates guardrails for a clear and transparent exemption process. There are five exemptions to fail first:

1. You have already tried and failed the medication the insurance company is requiring.
2. You will have irreversible damage if there is a delay in proper treatment.
3. The insurance required medication can cause harm to you.
4. You won’t be able to perform daily activities if you must take the required drug.
5. You are stable and managing your disease well on your current medication.

In addition to these guardrails, the Safe Step Act would also require a group health plan to respond within 72 hours – 24 hours if an emergency – to you or your doctor’s request for these exemptions.

For more information on how this works, watch this NPF short video.

Benefits for my son

My son was diagnosed at age 4 with psoriasis and age 5 with psoriatic arthritis. He has taken biologics since age 7. Creams and ointments didn’t work. He couldn’t tolerate the side effects of being on the highest dose allowed for methotrexate. Cyclosporine caused damage to his kidneys. He cycled through so many biologics we lost count. However, for the past 5 years, he’s found the one that works for him. Aside from occasional psoriasis breakouts and flares of joint paint and swelling, he is doing quite well.

Having to start back at the most basic of disease therapies would likely cause further joint damage. He just can’t take that risk. With the Safe Step Act, my son and his doctors would be able to file exemptions if required to take these less effective medications or ones known to have consequential side effects.

The SAIM Coalition brings together patient advocacy organizations, healthcare providers, and drug manufacturers to craft and advance state-based public policies to improve patient access to medications. Watch one of its patient interviews with Katie Roberts, a psoriatic arthritis patient who experienced step therapy.

New congress, new bill

In 2020, the Safe Step Act was introduced in Congress, but since it was not voted on in time, the process of introducing and cosponsoring the bill starts back at square one with our new Congress. Ask your representative and senators to cosponsor the Safe Step Act so that 2021 is the year for federal step therapy guardrails.