Step therapy protocols force patients to fail on cheaper drugs before accessing prescribed treatment

Insurers require "step therapy" (fail-first) protocols where a patient must try and fail on one or two cheaper medications before the insurer will cover the drug their doctor actually prescribed, even when the doctor has clinical reasons to skip the cheaper options. A rheumatoid arthritis patient whose doctor prescribes a biologic must first spend 3-6 months on methotrexate, experiencing documented liver toxicity risks, before the insurer approves the biologic. This costs the healthcare system more in the long run because failed therapies generate additional office visits, lab tests, and ER visits. Step therapy persists because PBMs negotiate rebates on preferred drugs, and every month a patient stays on the cheaper drug saves the insurer money regardless of patient outcomes, and override requests require physicians to spend 30+ minutes on peer-to-peer calls.