What is step therapy?

Imagine going to the pharmacy to fill a prescription, only to be told that step therapy is required before receiving a prescribed medication. This common occurrence can leave people feeling frustrated and unsure of their next steps. Understanding how it works can help avoid being unprepared or overwhelmed if unfamiliar with step therapy.

Step therapy focuses on using cost-effective treatments for various conditions, which may help save money in the long run for insurance companies and the people they cover. However, step therapy rules may cause delays in obtaining the best medication needed at the right time.

What is step therapy?

Step therapy is a process used by health insurance companies to manage and control prescription drug costs. Also known as “fail first” or “step protocol,” this process requires patients to try lower-cost medication options before using more expensive treatments. In essence, individuals may be asked first to try a lower-cost medication, such as a generic drug, in order for coverage determination to be decided.

Prior authorization vs. step therapy

Prior authorization and step therapy are two different things insurance companies might do when deciding if they’ll cover the cost of certain medications. 

• Prior authorization means a doctor has to get approval from the insurance company before certain medications can be prescribed. It’s like getting permission first. 
• Step therapy, on the other hand, is a specific type of prior authorization. With step therapy, the insurance company wants patients first to try cheaper or safer medications. They’ll approve the more expensive drug or complex medication if those don’t work. 

While both involve rules about getting medication, step therapy is more about trying cost-effective medications before trying brand-name or more expensive drugs. Step therapy programs generally outline the steps for patients to follow based on the prescription drug coverage requirements set by the insurer.

Why is step therapy important?

By requiring patients to try less expensive medications proven to be effective, step therapy can generate savings for both the patient and the health plan. However, critics argue that it may disrupt the patient’s care, especially if their doctor recommends a medication that is not the insurer’s preferred choice. To address these concerns, protections may be put in place to ensure step therapy requirements don’t hinder patients’ access to the appropriate treatment.

Which insurance plans use step therapy?

Step therapy is covered by various insurance plans, including commercial health insurance, Medicare, Medicaid, and even some Veterans Affairs (VA) plans. Insurance companies may require patients to follow this step-by-step approach and try preferred medications before they cover non-preferred, often pricier, options.

Medicare

Medicare plans, including Medicare Advantage plans and Medicare Part D prescription drug plans, are often known to require step therapy. Medicare Advantage plans apply step therapy mostly to Part B drugs like injectables and biologics, while Part D plans may use it for various prescription medications. 

Commercial insurance plans

Commercial health insurance plans also often have step therapy protocols to encourage the use of cost-effective, evidence-based treatments. These health insurance plans may include employer and private insurance plans, like those offered by Blue Cross and Blue Shield.

Though step therapy is common, not all insurance providers require it for every medication or therapeutic category. For instance, generic medications generally don’t require step therapy and are automatically covered. However, in some cases, not requiring step therapy has led to detrimental results. A study by the Johns Hopkins Bloomberg School of Public Health found that few health insurance plans used step therapy for opioids in 2017, which may have contributed to the opioid epidemic. 

Some states also have step therapy legislation, providing certain protections and exemptions depending on the individual’s insurance plan. One may want to review their specific insurance policy to determine whether step therapy applies to prescribed treatments.

What medications require step therapy?

The medications that require step therapy may vary from one insurance plan to another. In step therapy, the first-line alternatives are commonly generic drugs proven effective and safe for treating specific medical conditions. They are chosen after a thorough evaluation by the insurance company’s medical and pharmacy experts. 

The list of drugs involved in step therapy can differ among insurance plans. Examples of common medications that may require step therapy include alendronate or ibandronate for osteoporosis treatment and various medications for high blood pressure, arthritis, and asthma. 

Insurance companies typically base their decisions on their formulary and step therapy on clinical guidelines, scientific research, and expert input from healthcare professionals. In this way, insurance companies seek to cover evidence-based treatment options while managing prescription drug costs for both them and the patient.

Remember that step therapy programs are not static and can change over time. New prescriptions may be added or removed from the list of drugs requiring step therapy by an insurance plan. Therefore, staying up-to-date about the specific insurance policy and discussing any concerns or questions with a healthcare provider is advisable.

What to do if step therapy is required

Needing to go through step therapy can be a stressful situation, especially if a healthcare provider believes a more costly medication is necessary for specific medical conditions. In these cases, it may be helpful to be aware of the options available to navigate step therapy restrictions.

Contact your healthcare provider or health insurer

If a prescription needs to be filled immediately, speak with the prescribing healthcare provider and your insurance company as soon as possible. In some instances, a healthcare provider can request prior authorization to override step therapy requirements. This authorization is a formal request made by a provider to the health plan to approve coverage for a specific medication. The provider will need to provide information supporting why the cost-effective alternative is not appropriate for your condition.

Appeal step therapy restrictions

There are certain exceptions to step therapy, depending on your health plan and the medical necessity of the treatment. A healthcare provider can help determine if an exception applies to your situation. If an exception is not applicable, you have the right to appeal the step therapy restrictions. Your insurance company should have an appeals process, which may include providing additional documentation to support the need for the more expensive medication.

To wrap up, here are some tips for pharmacy customers who encounter step therapy restrictions:

• Communicate with a healthcare provider and insurance company as soon as possible.
• Ask a healthcare provider about the possibility of prior authorization to override step therapy requirements.
• Explore exceptions to step therapy based on specific medical conditions and health plans.
• Be prepared to appeal step therapy restrictions through the insurance company’s process.
• Consider using services like SingleCare to save on medications not covered by insurance.