Fail First Hurts

WHAT IS A FAIL FIRST POLICY?

Fail First policies — also known as Step Therapy — are an approach to prescribing drugs that insists the least expensive drug in any class be given to a patient first. If it works, good! If not, then the next least expensive drug must be tried … and so forth.

Fail First is used by health insurers to control costs. It is time-consuming from a physician and patient standpoint, is more expensive from a direct and indirect out-of-pocket cost perspective, denies patients the drugs they need when they need them, and allows payers to practice medicine without a license.

HERE’S WHY FAIL FIRST HURTS

• Creates additional barriers leading people to forgo needed medications
• Can cause patients’ medical conditions to deteriorate, increasing the need for medical intervention in the future. As a result, patients require increasingly costly medical care
• Increases frustration and incidents of depression
• Increases the risk of non-compliance and self-medication

JANET SCOTT’S REAL LIFE STORY

“My name is Janet Scott.  Just recently, I was refused a prescription of Savella and my pharmacy filled Effexor in its place for my fibromyalgia.  I was told by my insurer (Heating Piping and Refrigeration Medical Fund) that I need to speak to Express Scripts, because they no longer handle prescription coverage and have transferred the coverage for all prescriptions to Express Scripts.  The phone conversation with the patient advocate person went around in circles as she told me i cannot have the Savella, until I went through Fail First (step therapy).  I could not believe it, my doctor had told me that it’s time to start Savella, so I should take Savella not Effexor.  I have been through various other drugs for my chronic pain, and not to mention the round the clock Tylenol and Ultram to alleviate some pain.  I refuse to take a drug that do not work for me, it’s time for us to join together in our efforts to eliminate Fail First.”

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“Can someone tell me how Step Therapy can be legal? As I see it, when a physician sees a patient and writes a prescription, that drug should be dispensed. How does an insurance company or pharmacist (or for that matter a physician in their employ) who has never seen the patient, have the opportunity to provide any input into the treatment of that patient? It is unethical and grounds for a lawsuit if a physician prescribes a drug to a patient without seeing the patient. What gives the insurance company the right to do so? Seems to me this is a loophole that the companies are exploiting, and we need to stop it!”

– Ananth Annapragada, patient

BACKGROUND

Fail First policies — also known as Step Therapy — are often an insurance practice which requires the least expensive drug in any class to be prescribed to a patient first, even if a patient’s physician believes a different therapy is medically in the best interest for their condition.

There are currently no time limits or restrictions placed on these Fail First policies. Patients, including those with serious and degenerative medical conditions, can be forced to prove that cheaper and often less effective treatments have failed to adequately treat a patient’s condition for an indefinite period of time before the agent initially prescribed by the physician is paid for by the insurance company.

This practice has the potential to result in serious negative consequences for consumers and the public health system. By limiting the array of medication options, both physicians and consumers are forced to compromise their treatment decisions in a way that is dangerous, time consuming and more expensive in the long-term.