Step Therapy

Extended Definition

Step therapy, also known as “fail first,” requires patients to try certain treatments in a specific order before insurance will cover other options. The idea is to ensure simpler or less costly treatments are attempted before moving to more expensive alternatives.

How It Works for Joint Pain

A typical step therapy protocol might require:

Step 1: Conservative care

• Physical therapy
• Over-the-counter medications
• Weight management

Step 2: First-line medical treatment

• Prescription NSAIDs
• Basic bracing

Step 3: Injections

• Corticosteroid injections first
• Then hyaluronic acid injections

Step 4: Advanced treatments

• More invasive procedures
• Surgery when appropriate

Common Step Therapy Requirements

For HA injections, insurers may require:

• Trial of oral NSAIDs (2-4 weeks)
• Physical therapy attempt
• Corticosteroid injection first
• Documentation of each step failing

Pros and Cons

From Insurer Perspective:

• Controls costs
• Ensures appropriate care
• Evidence-based approach

Patient Concerns:

• Delays effective treatment
• May require failing treatments you’ve already tried
• One-size-fits-all approach
• Previous treatment not always counted

Getting Around Step Therapy

Exception requests may be granted if:

• You’ve already tried the required step
• Medical reason prevents the required step
• Step therapy would cause serious harm
• Your doctor provides compelling documentation

Documentation needed:

• Previous treatment records
• Reasons for contraindication
• Letter from your doctor
• Any relevant test results

Tips for Patients

• Ask about step therapy requirements upfront
• Keep records of all treatments tried
• Get documentation from previous doctors
• Know your plan’s exception process
• Appeal if inappropriately applied