To control drug costs and reduce the use of expensive medications, insurers have long relied on step therapy, a restriction on insurance coverage that requires patients to prove that less-expensive drugs are ineffective before getting coverage for a more expensive, higher-tier drug. Step therapy is another form of a prior authorization, but many argue that step therapy undermines the patient’s health and prevents them from accessing appropriate treatment.
So, what does step therapy look like, and how can you stay sane if your insurer needs it from you? Here’s what you need to know.
What is step therapy?
Before some plans cover certain expensive drugs, they want to check that other more affordable drugs don’t work for you first. This may mean that you have to try multiple drugs before you can get coverage for the right medication.
In step therapy, drugs are grouped into two different categories:
- First-choice drugs (also known as front-line or first-step drugs) — These are the generic and lower cost, brand-name drugs that you will need to try before your insurer will cover the more expensive drug.
- Second-choice drugs (also known as back-up or second-step drugs) — These are the less preferred and more costly treatment options.
If you submit a prescription at the pharmacy for a drug that requires step therapy, your pharmacist will contact your physician, who will write you a 30-day prescription for a less expensive first-choice drug. If, after 30-days, that first-choice drug is not adequately treating your condition, your doctor can fill out an override, or exception form, and send it to your insurer to request that they cover the more expensive second-choice drug. This usually results in successful coverage, but unfortunately, your insurer can deny the request and leave you on the hook for the full price of the medication.
What drugs require step therapy?
Insurers will typically require step therapy for expensive, brand-name drugs that have affordable alternatives, but the actual list of drugs will differ plan to plan. Some examples of these drugs include Differin, Clarinex, Abilify, Fenoglide, Nexium, and Prilosec.
Contact your insurer or check your plan’s drug formulary to see if your drug will require step therapy.
I was denied coverage for my drug. What do I do now?
If your insurer denies coverage for your drug, even after you have gone through step therapy, consider an appeal. (Not every insurer allows step therapy appeals, so contact yours to discuss your options.) If you decide to appeal, one of the best ways to build your case is to get your doctor’s input. Ask them about any backup documentation or medical notes that could help you prove your prescription is medically necessary.
If that doesn’t work or you need your preferred medication immediately, you still have options. Talk to your doctor about alternative medications that don’t require step therapy, as most plans offer coverage for one or more alternatives. If using a covered alternative isn’t possible, ask your doctor about filling a 90-day supply, which can be more affordable than a 30-day supply. Your doctor may also have free samples of the drug you need. If you qualify for a patient assistance program or manufacturer discount card, they can also help you save. Search for your drug on GoodRx.com and look for the “Savings Tips” tab on the left for more information.
Lastly, don’t forget to shop around. In many cases, GoodRx can help patients save as much as 80% off of the cash price of their medication.
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For more on coverage restrictions and how to get the medications you need:
- Prior Authorization: What to Do When You Can’t Wait for Prescription Coverage
- Prescription Quantity Limits: What to Do When Insurance Plans Limit Coverage