Step Therapy
Step therapy is a rule requiring you to try a lower-cost drug before the plan will cover a more expensive alternative. If the first drug does not work, your doctor can request approval to move to the next option.
Understanding Step Therapy
Step therapy is a cost-control rule used by Medicare drug and Advantage plans. Before the plan will cover a more expensive medication, it requires you to first try one or more lower-cost, clinically appropriate alternatives. Only if those do not work — or your doctor documents a medical reason — will the plan approve the costlier "step up" drug.
For beneficiaries, step therapy can delay access to a specific medication and adds paperwork, but it can also lower your costs when a generic works just as well. If the required first-step drug is not right for you, your doctor can request an exception, and you have the right to appeal a denial.
For example, if your doctor prescribes a brand-name arthritis drug, the plan may require you to try a generic anti-inflammatory first. If that generic causes side effects, your doctor submits documentation and the plan then approves the brand-name option.
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Related Terms
Prior Authorization
Prior authorization is approval you must get from your plan before certain services or drugs will be covered. Without it, the plan may not pay for the service.
Formulary
A formulary is a list of prescription drugs covered by a Medicare drug plan. Drugs are organized into tiers, with different cost-sharing for each tier.
Formulary Tier
A formulary tier is the cost level a drug plan assigns to each covered medication. Lower tiers (preferred generics) have the lowest copays, while higher tiers (brand-name and specialty drugs) cost more.
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