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What is Step Therapy? How to Get Insurance to Pay for Your ‘Non-Preferred’ Medication

Alex Evans, PharmD, MBAAlyssa Billingsley, PharmD
Updated on February 21, 2023

Key takeaways:

  • Step therapy is when your insurance company requires certain steps before they’ll pay for your medication. Usually, this means you’ll have to try taking a preferred medication before they’ll pay for a non-preferred one.

  • Insurance companies use step therapy to control cost. It’s also used to help prevent you from taking a medication that’s not the best choice for your symptoms. But step therapy may make it harder for you to get your medication.

  • Sometimes, your insurance company will let you skip step therapy. But this usually requires your healthcare provider’s help. They have to give a reason why the insurance company’s preferred medication isn’t a good choice for you.

A person holding a pill bottle and typing on their laptop.
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Before prescription insurance plans will pay for certain medications, they want to make sure that other, more affordable or appropriate medications don’t work for you first. This may mean that you’ll have to try a different medication before you can get coverage for the one your healthcare provider prescribed. And this process is called step therapy.

Essentially, step therapy is a type of prior authorization — a restriction your insurance company puts in place to determine whether or not they will pay for certain medications. Many argue, however, that step therapy may negatively affect your health and make it harder for you to get the medication you need. 

If you’ve been placed in the step therapy process, it might feel a bit overwhelming. To help you navigate this process, we’ll run through what step therapy looks like and what you should do if you run into a step-therapy rejection claim from your insurance company.

What is step therapy?

As discussed, insurance companies use step therapy as a way to control cost and avoid unnecessary medication use. So, if they deem there’s a medication that’s less expensive than what your healthcare provider prescribed for you — and it’s still effective for your condition — they’ll make sure you’ve tried that first. 

In step therapy, medications are typically grouped into multiple steps. Medications in the lowest step (step one) are usually covered without any issues. These are often generic medications, but not always. 

Before paying for a medication in the next step up, your insurance company requires proof you can’t take a step one medication. Or that you tried it and it didn’t work for you. The number of steps differs for each insurance company. But two or three steps is common.

What medications require step therapy?

Step therapy is often used for expensive, brand-name medications that have more affordable substitutes. But sometimes it’s because the medication isn’t the first choice for your symptoms. For example, BlueCross BlueShield of Illinois requires step therapy in many cases to make sure you’re taking the right medication for your condition.

The list of medications that need step therapy will differ between insurance plans. Here are some examples of medications that need step therapy approval from a number of different plans:

You can contact your insurance company or go to their website to find their preferred medication list. There, you’ll find information about specific medications. This includes whether they’re covered, if they require step therapy, and if there are limits on how much or how often you can get them.

I was denied coverage for my medication. What do I do now?

If your prescribed medication requires step therapy, your pharmacist will receive a message from the insurance company once they submit a claim for it. After that, they’ll work with your healthcare provider to find the right solution for you. Below, we’ll detail some of the scenarios and outcomes you can expect in this process.

  1. Try step one. You’ll likely need to try a medication that’s in step one first. If it doesn’t work, then a medication in the next step is more likely to be covered. But if none of the medications in step one are a good choice for you, your healthcare provider may be able to help. They can ask for an exception from the insurance company.

  2. Rejection and appeal. Sometimes, your insurance company may still deny coverage for your medication, even after you’ve gone through step therapy. If this happens, you can try 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 healthcare provider’s input. Ask them about any documents or medical information that could help you prove your prescription is necessary.

  3. Avoid step therapy. If that doesn’t work, or you need your medication immediately, you still have options. Talk to your healthcare provider about other medications that don’t require step therapy, as most plans offer coverage for one or more other options. They may also have free samples of the medication you need.

  4. Try other ways to save. If you qualify for a patient assistance program or manufacturer copay card, they can also help you save if you want to pay for the medication out of pocket. Search for your medication on GoodRx.com and look for the “Ways to Save” section for more information on what programs are available. Lastly, don’t forget to shop around. In many cases, GoodRx can make your medication more affordable.

Whatever you do, it’s important to get treatment for your medical condition. Don’t ignore your health, even if you need to do extra work with your insurance company to get the medication you need. And you don’t have to do it alone — your pharmacist and healthcare provider are here to help.

The bottom line

Step therapy is a type of limit on prescription coverage. Insurance companies use it to control cost and prevent unnecessary medication use. But it may also prevent people from getting the medicine they need.

If your medication requires step therapy, you have options. Ask your healthcare provider to contact your insurance company or prescribe another medication for you. There may also be discounts available from the manufacturer, patient assistance programs, or with a free GoodRx discount to help you save.

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Why trust our experts?

Alex Evans, PharmD, MBA
Alex Evans, PharmD, MBA, has been a pharmacist for 12 years. His first job was floating in a community chain pharmacy.
Stacia Woodcock, PharmD
Stacia Woodcock, PharmD, is a pharmacy editor for GoodRx. She earned her Doctor of Pharmacy degree from the University of Kentucky and is licensed in New York and Massachusetts.
Alyssa Billingsley, PharmD
Alyssa Billingsley, PharmD, is the director of pharmacy content for GoodRx. She has over a decade of experience as a pharmacist and has worked in clinical, academic, and administrative roles.

References

BlueCross BlueShield of Illinois. (n.d.). Prior authorization/step therapy program.

Burgy, J., et al. (2020). To limit the harms of step therapy, implement robust standards and protect physician autonomy. Health Affairs

View All References (5)
GoodRx Health has strict sourcing policies and relies on primary sources such as medical organizations, governmental agencies, academic institutions, and peer-reviewed scientific journals. Learn more about how we ensure our content is accurate, thorough, and unbiased by reading our editorial guidelines.

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