PBMs, Step Therapy & Medication Access

Article contributed by Prarthana Jain, DO MPH

For rheumatologists, choosing the right medication is often only the first step. Actually getting that medication into a patient’s hands can be much harder.

Prior authorizations, formulary restrictions, pharmacy benefit manager (PBM) requirements, and step therapy are now routine parts of caring for patients with rheumatic disease. While these policies are intended to control health care costs, they can also create significant barriers to timely treatment.

The Challenge of Step Therapy

Step therapy may require patients to try an insurer-preferred medication before receiving coverage for the treatment their physician recommends.

In some situations, this can be reasonable. The problem is when these requirements do not account for disease severity, previous treatment failures, contraindications, or other individual clinical factors.

For patients with inflammatory rheumatic disease, delays matter. Uncontrolled disease can lead to irreversible joint or organ damage, loss of function, and greater health care costs over time.

These requirements also create a significant administrative burden. Rheumatology practices spend considerable time on prior authorizations, appeals, and specialty pharmacy coordination, all of which could otherwise be spent caring for patients.

Progress in North Carolina

North Carolina has taken important steps to address some of these concerns. Recent reforms have increased oversight and transparency of PBMs, while state law provides an exception process for step therapy and other restricted-access medications when clinically appropriate.

These are meaningful steps forward, but what matters most is how they work in practice for patients. Patients should not have to repeat therapies they have already failed, and those doing well on an effective treatment should have reasonable continuity of care.

How Rheumatologists Can Help

Rheumatologists see firsthand how medication access policies affect our patients. We encourage rheumatologists across the state to stay engaged and advocate for policies that reduce unnecessary delays in care.

This can include documenting when step therapy or formulary restrictions delay treatment, sharing recurring access issues with NCRA, and participating in state and local policy efforts when opportunities arise. Real examples from our practices can help policymakers better understand how these policies affect patient care.

By working together, we can help ensure that efforts to control health care costs do not come at the expense of timely, effective treatment.