Step Therapy

Step Therapy

Where We Stand

NAMI believes that all people with mental health conditions deserve access to effective medication and treatment options. NAMI supports public policies and laws that prohibit step therapy for psychiatric medications.

Why We Care

Mental health medications affect people in different ways, and individuals need to be able to access the medication that works best for them and their individual health needs. It is important that medication decisions are carefully considered with a health care provider who has both extensive knowledge of the individual and available medication options.

Sometimes, health insurers may request or require patients to demonstrate unsuccessful treatment on one or more insurer-preferred medications before they receive coverage for the medication that their physician recommends. This practice is also known as “step therapy” or “fail first,” meaning that an individual must “fail” on one or more medications before they can try another that may be recommended by their health care provider. Step therapy results in patients not being able to access the treatments they need in a timely manner.

Step therapy can be a danger to the health and well-being of the person taking the medication, and result in a worsening of symptoms and undermining the decisions made between individuals and their health care providers. Instead, policies should maintain access to provider-recommended medications and should specifically prohibit step therapy for psychiatric medications, or, at a minimum, establish clear, rapid timelines for insurer responses to requests for exceptions and ensure that people who have previously used a medication do not have to switch.

How We Talk About It

  • For many people with mental illness, medication is an essential part of their treatment and can be a valuable tool in overall well-being.
  • For individuals who take medications for their mental health condition, one size does not fit all.
  • Mental health medications affect people — even those with the same diagnosis — in different ways, including varying levels of effectiveness and different side effects. Because of this, it is important that a person can access the medication that works best for them.
  • Some insurers may use “step therapy” (or “fail first”) policies that require a person try one or more insurer-preferred medications unsuccessfully before they receive coverage for the medication that their doctor recommends.
  • For some health conditions, people can switch to a different drug without problems. However, for people with mental health conditions, step therapy has unintended — and sometimes dangerous — consequences.
  • The use of mental health medications is a decision made between an individual and their health care provider based on their symptoms, treatment history and consideration of side effects.
  • When a health insurer requires step therapy, it can pose serious risks to a person taking mental health medication.
  • While step therapy is often promoted as a cost-savings strategy, policies that restrict access to medications can cause negative outcomes, sometimes leading to emergency department visits, hospitalizations, homelessness or criminal justice involvement.
  • The cost to individuals, families and communities when a person must fail on a medication before getting what they need is too high.
  • Mental health medications should be exempted from step therapy policies. At a bare minimum, policies should establish clear, rapid timelines to requests for exceptions and ensure that people who have previously used a medication do not have to switch.
  • Step therapy risks the safety of people with mental health conditions. State and federal policies should protect — not jeopardize — access to mental health medications.

What We’ve Done

  • NAMI is a member of the State Access to Innovative Medicines (SAIM) Coalition to advocate against step therapy.
 

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