Step Therapy for Medicine

If your health insurer has denied a prescription and requires you to try other medicines first, you are likely dealing with step therapy. This is a method that insurers use to keep medicine costs down.

Step therapy requires a person to try lower-cost medicines first, before that person's insurer approves the higher-cost medicine that was prescribed.

Being denied a needed medicine can be stressful. Take a closer look at how step therapy works and how to work with both your doctor and your insurer to get the best care possible.

Step therapy is a way that health insurers try to control the cost of the medicines they pay for. It's a type of prior authorization. The insurer requires you to first try one or more lower-cost medicines before they will cover a higher-priced medicine that your doctor has prescribed.

This is also called the “fail first” approach. That's because the first few medicines must fail to work before the insurer will approve the more costly medicine your provider wants you to take.

Finding out your medicine is not covered due to step therapy can be concerning because it:

• Forces you to try medicines that may not work as well. Often these first-step, lower-tier medicines are older. They may not work as well as the medicine your doctor prescribed.
• Delays your treatment. While you are taking the time to try the lower-tier medicines, you are not getting the treatment that you need.
• Can lead to health complications. The delays in getting the correct medicine needed for your condition may put your health at risk.
• Often affects people with complex conditions. Step therapy is often used for chronic or complex conditions that require certain medicines and treatment.
• Goes against what your doctor advises. It's stressful not to be able to use the medicine that your doctor believes is best for you.

Your doctor can help you work through the step therapy process or find other options if possible.

Step therapy affects many high-cost medicines that are used for many types of complex and long-term (chronic) conditions. These are conditions that often require very focused medicine and treatment, such as:

• Cancer.
• Neurological conditions.
• Autoimmune conditions.
• Rheumatology conditions.
• Inflammatory bowel disease.
• Respiratory conditions such as asthma.

It's possible you may not know that step therapy is required until you are at the pharmacy to pick up your medicine. If this happens, and you can't get the medicine your doctor prescribed, then:

• Talk with the pharmacist. Find out what the insurer told the pharmacy. You'll likely have to get a first-step medicine that your insurer requires.
• Talk with your doctor. Let them know that you weren't able to get the medicine they prescribed. If you got a different medicine, let them know. Ask them if this is safe for you to take. Find out how you can work together to get the medicine you need.
• Contact your health insurer. Ask them why your preferred medicine was not approved. Ask for details about the step therapy program for your health plan. Find out where to find a list of the medicines that require step therapy.

It's important to work closely with your doctor. They can help you work through step therapy to get you the medicine and care that you need. Many times, your doctor will know if a medicine is subject to step therapy. Your doctor may have staff who can also work with your insurer to complete the preauthorization process. When meeting with your doctor:

• Know what your health plan requires. Each health plan is different. So be sure to learn about the step therapy program for your plan. Also find out which medicines your insurer will cover. Show this list to your doctor. You may actually end up with a less expensive medicine that is better and more convenient for you. An example might be an asthma inhaler that you only have to take once a day (instead of twice).
• Keep good records. It's helpful to keep a detailed paper or electronic file. Keep a record of information about your conditions and medicines:
  • Ask questions about any new medicines that are prescribed. If your doctor prescribes a new medicine, ask if they know if insurers are covering it.
  • Ask about other medicine options. Be proactive. Ask your doctor what other medicines they can suggest if your health insurer won't approve this new medicine.

Your doctor may also suggest other ways to try to get the needed medicine, such as:

• Using prescription medicine coupons. You may be able to get coupons for the preferred medicine online or at your doctor's office. These coupons can lower the price you pay for medicines. They are offered by pharmaceutical companies for certain medicines. Coupons reduce your insurance copay or your out-of-pocket cost.
• Contacting your insurer about your case. Your doctor may contact your insurer with key details to help you get the preferred medicine. For instance, they can let the insurer know if you have already tried the step therapy medicines and they did not work for you. Or your doctor can let them know if these lower-tier medicines won't meet your health needs.