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

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.

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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:

• Cigna: vortioxetine (Trintellix), suvorexant (Belsomra), and cariprazine (Vraylar).

• Humana: pitavastatin (Livalo), diclofenac (Zorvolex), and insulin glulisine (Apidra Solostar).

• Express Scripts: Eletriptan (Relpax), desvenlafaxine (Khedezla), and vilazodone (Viibryd).

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.

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Written by:

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.

Edited by:

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.

Reviewed by:

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.

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