NFMCPA Speaks Out Against “Step Therapy” for Fibromyalgia and Chronic Pain Patients

Karen Lee Richards Health Guide
  • Last week the National Fibromyalgia & Chronic Pain Association issued a position paper calling for an end to health insurance company practices that require the use of step therapy, fail-first or special tiers when prescribing medication for patients.  The paper describes these practices as “insufficient treatment options which needlessly prolong the suffering of fibromyalgia and chronic pain patients.”

    In an effort to control ever-increasing medical costs, many insurance companies have instituted one or more of these approaches to the use of prescription drugs. 

    Step therapy, sometimes called fail-first, requires patients to try one or more lower-cost medications and fail before the insurance company will cover more expensive prescription drugs.  The lower-cost medications are usually either over-the-counter or generic prescription drugs; the more expensive medications are generally the newer prescription drugs on the market.

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    Special tiers refers to a plan that places certain very expensive specialty drugs in a separate category from other prescription medications.  While patients may have a standard co-payment for most prescriptions, they are required to pay a percentage of the total cost for these specialty drugs. 

    The NFMCPA is the first nonprofit organization to issue a paper on this subject specifically addressing and advocating for the needs of the fibromyalgia and chronic pain patients.  You can read their position paper here:

    “Position Paper on Access to Care for Step-Therapy, Fail-First, and Special Tiers”

    Jan Chambers, president and founder of the NFMCPA, also discusses the issue on BlogTalkRadio.  (Note: During the broadcast she lists the states which are currently considering legislation to prohibit insurance companies from using these practices.)


    Listen to the broadcast:  "Step Therapy" Fails for Fibromyalgia Patients

    My Thoughts...

    I completely agree with the NFMCPA's stand on this issue.  In my opinion, practices like step therapy and fail-first are, simply put, insurance companies practicing medicine without a license.  No one but the patient's doctor should decide which medication is best for him/her. 

    Delaying appropriate treatment can not only cause patients to suffer needlessly, it can sometimes cause permanent harm.  Fibromyalgia is a good example of this.  Since the only three drugs approved for the treatment of fibromyalgia are relatively new and still pretty expensive, patients would probably be required to try other older, less expensive treatment options first.  The problem is, the sooner a fibromyalgia patient is able to start on an effective treatment plan, the better their chances are for significant improvement.  Step therapy and fail-first plans could potentially rob fibromyalgia patients of the opportunity to get better. 

    As for special tiers plans, I think they are just plain cruel.  Typically medications that fall into the special tiers category are life-saving drugs for illnesses like cancer, lupus, HIV/AIDS, multiple sclerosis, etc.  They are also usually extremely expensive, which is why they are placed into the special tiers category to begin with.  Paying a percentage of the cost of these medications – even as little as 20 percent – could run into hundreds or thousands of dollars a month.  Prices like that would put these life-saving treatments out of reach for most of the people who desperately need them. 

  • Your Turn...

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    I want to hear from you on this issue.  I'm wondering just how prevalent these types of policies are currently and how they are affecting you. 

    • If you have health insurance, does your prescription plan use step therapy, fail-first or special tiers?
    • If so, how has it affected you?
    • Do you think states should pass legislation to prohibit insurance companies from using these plans?
    • What are your thoughts on this subject?


Published On: October 19, 2011