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Whether you go to a doctor for a chronic condition or a new medical problem, you want relief.
So when you learn that there’s a prescription medication that could potentially help, it can be frustrating to learn that you can’t just get it at the pharmacy.
In some cases, you have to go through something called a step therapy process first before your insurance covers the medication. Essentially, this means the insurance company classifies medications by three “step levels” and you must try those in the least expensive step first and work your way through the steps to get to various medications.
Step therapy may be required by any type of insurance plan, whether they are employer-offered, private or a Medicare Advantage Plan. Here’s what you need to know about the process.
Key Takeaways
Step therapy requires you to try less expensive drugs before using the pricier name-brand ones.
Do your homework before seeing the doctor. Check if your insurance plan requires step therapy.
If your insurance company requires it, your doctor may be able to get you an exception.
If your insurance denies coverage, don’t fret. You can appeal, ask for samples, get help from the drug manufacturer, or use a prescription savings program.
What Is Step Therapy?
To help control costs, insurance companies require prior authorization for certain medications.
This means your doctor has to get approval from the insurance company for a specific medication before the insurer covers it.
Step therapy, also known as “fail first,” is a form of prior authorization. Your doctor must prescribe a less expensive, step-one drug (such as over-the-counter or generic medications) first. If it doesn’t work (i.e., it fails), then your insurance will consider covering a costlier drug, like a lower-cost brand-name medicine. The process continues — after each drug fails to address the problem, the doctor is able to prescribe a drug in the next step, which is often a more expensive medication.
Step therapy is typically applied to drugs that treat chronic conditions, such as:
- HIV/AIDs
- Glaucoma
- Diabetes
- Cancer
- Hemophilia
- Epilepsy
- Alzheimer’s disease
- Mental health conditions and
- Autoimmune diseases
How Does Step Therapy Work?
As noted above, the step therapy process divides medications into three steps:
- Step 1: Generic medications, which are often automatically covered.
- Step 2: Preferred brand medications may require step therapy, meaning you may have to start with a step 1-level drug first.
- Step 3: Non-preferred brand medications often require step therapy. So if your doctor feels your treatment should start with a step 3-level medication, he or she will need to submit a prior authorization request to receive approval for the drug to be covered by your insurance.
Step therapy requirements may depend on your health condition. Generally, you must go through the three steps to have the most expensive medications covered.
What Are Pros and Cons of Step Therapy?
Step therapy is controversial, but there are both benefits and drawbacks for patients:
Benefits
- Potential savings: Medications on the first two step levels tend to be cheaper than step 3 level medications. If the lower-level drugs prove to be effective, step therapy can help you save money. Conversely, if you go straight to the more expensive step 3 medication, your insurance may not cover the full cost, and you may have to pay for it out of pocket.
- Patient safety: Because it requires a tiered approach to treatment, step therapy prevents doctors from making unusual treatment choices or prescribing riskier new medications. Instead, they have to try proven treatment options first.
Drawbacks
- Delays in care: You may have to wait to get the relief you need. In one survey, 50% of responding patients reported having to try two or more drugs before taking the medication their doctor originally recommended due to step therapy’s requirements.
- Decreased patient adherence: Because of delays in getting effective treatment and finding relief, some patients will stop taking medications altogether and won’t fill their prescriptions.
How Do You Know If Your Prescription Requires Step Therapy?
Take a few minutes to read your insurance plan’s summary plan description or certificate of coverage. The prescription drug section will tell you if the plan requires step therapy. That way, you’ll be prepared when you go to the doctor.
Each time your doctor prescribes a new medication, ask whether it’s a standard treatment or less commonly used, and why he or she is prescribing that particular medication. Then, before you take your prescription to the pharmacy, go online and look up your insurance plan’s formulary. A formulary is a list of prescription drugs that your insurance plan covers. If the medication requires step therapy, it will usually have an “ST” next to its name. You can also call your insurance company’s customer service line.
If step therapy is required, contact your doctor. There may be another medication he or she can prescribe to treat your condition without requiring step therapy. Or, they can prescribe a Step 1 level medication to start the step therapy process.
If your doctor feels it’s medically necessary to skip the step therapy process, you may be able to qualify for an exemption from your insurer. Discuss your situation with your doctor, who will then talk with your insurer to explain why you need the medication right away and why the restrictions should be lifted. Exceptions may be granted. For example: if you had a bad reaction to a lower-step level medication in the past (perhaps while covered under a different plan), are allergic to one of the medication’s ingredients, or a lower-tier drug would cause unwanted side effects. If the lower level medication is thought to interact badly with other medications you are taking, your provider should definitely work with your insurance company to avoid that particular drug.
What Do You Do If Your Insurance Company Denies Coverage?
If your insurance company denies coverage for the prescribed medication, you have a few options:
- File an appeal: Ask your doctor for documentation, including medical notes and any records about your condition, including potentially adverse reactions to the recommended alternative medications. Send in those records to your insurance company with your appeal.
- Ask for samples: If you need the medication right away and can’t wait for an appeal, ask your doctor if he or she has any samples or manufacturer’s coupons for the drug. The coupons will get you a discount if you have to pay out of pocket.
- Check with the manufacturer: Some pharmaceutical companies offer significant discounts if you pay a cash price for the medication rather than go through insurance. Others offer drug assistance programs for individuals who can’t cover the cost of their medication. Look up the drug and see if it has a website. The manufacturer will often list any discount programs on the main page.
- Use a prescription savings program: If your insurance doesn’t cover the medication, try a prescription savings card like FamilyWize or GoodRx to lower its cost. On average, users save 45% on their prescriptions.
Next Steps
If you need medication to treat a chronic medical condition, dealing with step therapy can be frustrating. But by understanding the process and insurer’s requirements, you can navigate through its criteria and get the care and medication you need.
