For many people living with psoriasis, finding a treatment that truly works can feel life-changing — clearer skin, fewer flares, and a sense of control. But before some people can access the most effective therapies, they may run into a frustrating hurdle: step therapy, often called the “fail first” policy.

Still, there are ways for patients and providers to navigate step therapy requirements — from requesting exceptions to making appeals — to ensure access to the treatment that’s ultimately needed.

What Is Step Therapy?

“In psoriasis care, this usually means starting with topical treatments before progressing to more advanced therapies if those options are not effective enough,” says Marisa Garshick, MD, a dermatologist in New York and New Jersey, and a clinical assistant professor of dermatology at NewYork-Presbyterian Weill Cornell Medicine.

On paper, the idea is straightforward. “We start with our step 1 treatment. If that doesn't provide control, we move to step 2. It sounds like a great idea … but the reality of step therapy is a little less than ideal,” says Steven Daveluy, MD, a professor and the program director at Wayne State University’s School of Medicine in Detroit, where he specializes in treating patients with skin diseases such as psoriasis and eczema.

“Sometimes step therapy is reasonable … other times [it] isn’t appropriate. If someone has psoriasis on a significant amount of their skin, it’s not reasonable to say they must try topicals before they can get an oral or biologic medication,” says Dr. Daveluy.

Why Does Step Therapy Exist?

Step therapy was around long before biologics, but it has become more common as newer, high-cost treatments have emerged. Its main goal is cost control.

“For this reason, insurance plans often require patients to try earlier, lower-cost treatments first to demonstrate that those options were not enough before approving access to these therapies,” Garshick says.

• The drug didn’t sufficiently improve symptoms.
• Side effects were intolerable.
• The disease continued to progress despite treatment.

How Step Therapy Works in Psoriasis Care

• Topicals First-line therapies include corticosteroids (such as clobetasol or betamethasone), vitamin D analogs (such as calcipotriene), and other nonsteroidal creams and ointments applied directly to the skin, Garshick says.
• Phototherapy If topicals aren’t enough, patients with moderate disease may be referred for medical-grade ultraviolet (UV) light treatment. In this case, LED lights at specific wavelengths are used to decrease skin inflammation and help to slow skin cell production.

• Oral Systemics Next up are older systemic drugs like methotrexate or cyclosporine, which suppress the immune system more broadly. These drugs are earmarked for severe cases of psoriasis and they come with a higher risk of liver disease or kidney damage.

• Biologics and JAK Inhibitors These are targeted, highly effective therapies that act on specific immune pathways — and they’re the most expensive, which is why insurers often require “failure” of other treatments before approving them.

While this stepwise approach may work for some, it doesn’t always align with what dermatologists consider the most appropriate or timely care. And access to these advanced therapies isn’t always straightforward.

“Insurance plans may require documentation that prior therapies didn’t work before approving biologics, which can make access slower. While the goal is to ensure appropriate and cost-effective care, it’s important to pick the treatment that will provide patients the most relief as efficiently as possible,” Garshick says.

And the step therapy process itself can vary widely.

“It’s really complicated,” says Daveluy. “Step therapy is different for each state, each insurance provider — and often for each plan within an insurance [program].” Some insurers require patients to try many first-line treatments before unlocking the next level of alternatives while others gain access to second-line treatments after just one “fail,” he says.

Another common challenge is when insurance plans add new drugs to their step therapy lists, forcing patients to “fail first” on medications they’ve never tried before, even if those options are less likely to help, Garshick says.

And if they change insurance providers, the new insurer may require them to repeat the step therapy process from the start, she says.

Real-World Impact on People With Psoriasis

While step therapy is designed to control costs, its real-world impact on patients can be significant.

Delays in Effective Treatment Moving from topicals to systemic treatments can take weeks to months, and transitioning to biologics can take even longer due to prior authorizations and insurance requirements, Garshick says.

Daveluy notes that patients may need to try a medication for around three months before insurers consider it a failure, extending the timeline even further.

Ongoing Symptoms and Flares During that time, patients may be dealing with active disease. “Patients are often flaring with serious psoriasis that impacts their daily life … they may have to settle for a treatment that is less than ideal for their preferences and needs,” Daveluy says.

The stress from ongoing flares, itching, and scaling can take a toll on mental health, too. This is parallel to trying medications patients suspect won’t work and managing insurance paperwork. “While step therapy aims to control costs … it can unintentionally prolong suffering,” Garshick says.

The onus is on patients and their doctors to pull together the paperwork needed to make their case to insurance providers, Daveluy says. “Authorizations often need to be renewed each year, even when a treatment is working. That can also cause delays in care that result in flares,” he says.

How to Get the Treatment You Need

If you’re navigating step therapy, being informed, organized, and proactive can make a real difference. Here’s what to do.

Understand your insurance formulary. Study your policy and learn which medications are covered — and which require step therapy or prior authorization. “Try your best to understand your insurance formulary,” Daveluy says.

Keep detailed records. Track every treatment you’ve tried, including dates, side effects, and results. “Keeping a diary can be helpful when documenting treatment failure,” Garshick says.

Work closely with your dermatologist. Your doctor can submit prior authorizations, write letters of medical necessity, and file appeals when needed. Stay on top of renewal dates, too. “Authorizations often need to be renewed each year, even when a treatment is working. That can also cause delays in care that result in flares,” Daveluy says.

Be proactive and persistent. Advocate for yourself, Garshick says. If something isn’t working, speak up early. And if a claim is denied, don’t stop there.

“You pay the insurance company, and they owe you a service,” Daveluy says. Patients can also call insurers directly to clarify requirements — or even file a complaint if they believe the process is unreasonable.

Request an exception when appropriate. In some cases, doctors can bypass step therapy requirements if a medication is medically necessary or more appropriate for your condition, Garshick says. This is especially the case “when disease severity or quality-of-life impact warrants it,” she says.