Step therapy for medications
What is step therapy?
Sometimes, before your insurance plan will pay for an expensive medicine or therapy, you need to try similar but less expensive treatments first. This process is called step therapy.
Insurance companies have a series of safe and effective treatments to try before you step up to the more expensive one. The number of these steps depends on your insurance plan and the medication. You can ask your doctor or pharmacist to check if step therapy is needed for your medicine.
Since step therapy typically starts with generic drugs with lower copays, the process can help you save money by finding effective treatments at a lower cost.
Common uses of step therapy
How step therapy works
After your doctor sends your prescription, you may receive a notice saying that lower-cost treatments must be tried before your new medication is covered by insurance.
You can work with your doctor to start with the approved alternative. To move to the next step, or more expensive therapy, you need to meet at least one of the following reasons:
- You can show that you have already tried a similar generic.
- You have an allergy or intolerance to the similar generic.
- The generic medication did not effectively treat your condition.
- You have an FDA-labeled contraindication to the generic drug.
Your doctor must give medical records explaining your reason to step up to another medication. You might need to try several drugs before finding one that works for you.
Navigating the process
First, you'll want to review your formulary. Check your plan's list of approved drugs to understand what medications require step therapy for your condition. Work with your doctor to gather the records needed for an exception or to appeal a decision.
Make sure to keep detailed track of how you respond to each medication, including how well it works and its side effects. Ask your pharmacy and doctor how long approval might take so you can plan.
Appealing a decision
If your exception is denied, you may have the option to appeal. You should receive a reason why it was denied, giving you the chance to submit additional information.
To appeal a decision, your doctor can provide more details about your condition, health history, and any treatments you've already had.
Keep in mind that the appeals process can vary depending on your state's regulations.
