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Navigating Step Therapy: Part 1

Prescription drugs are a big part of the healthcare industry. In the US, as many as 3 billion prescriptions are written annually and millions of Americans rely on Rx drugs to sustain their health. With hundreds of different prescription drugs available, it’s important you’re prescribed options that are as safe, effective and affordable as possible.

As with certain medical procedures, some prescriptions require a type of approval process before your health insurance provider will cover the cost. One of the most common approval processes used by health plans is Step Therapy.

Navigating Step Therapy

What is Step Therapy?

Step therapy is used to make sure their members try different drug options before “stepping up” to more expensive prescription drugs. It’s a way to ensure that consumers aren’t overpaying for their medication. Members try more affordable drugs first. These “first-line” drugs are effective for most. If these prescription drugs are ineffective, the member goes onto try a more expensive prescription.

These “steps” are mandatory. The insurance company doesn’t cover the initial, immediate use of that more expensive prescription without the member trying out less expensive drugs first. This helps save the member money in the long-run. Finding an effective prescription drug for the most affordable price is the goal.

Let’s look for at example: you’re struggling with allergies. There are a lot of different prescription drugs on the market. Some cost significantly less than others and do not require Step Therapy. But, according to the terms of your health coverage, prescription “B” requires members to go through the Step Therapy process.

First, you try something over-the-counter. No relief there- you’re still suffering from sneezing fits during client meetings at work. So you visit your doctor. He prescribes prescription “A”. It’s a lower-cost option and part of the Step Therapy process. After a while on prescription “A”, you return to your doctor’s office to report “A” isn’t working either. Your doctor gives you a new script for “B”. “B” is more expensive but does the trick.

In this example, you followed the step therapy required by your health plan. Had you skipped trying the less-expensive prescription “A”, you’d have to dig into your own pocket to pay for part or all of prescription “B”.

How Do I Know If a Drug Requires Step Therapy?

There are a few ways to figure out if a prescription requires step therapy.

  • Many health plans list the prescription drugs that require step therapy right on their drug formulary (a list of prescription drugs, generic and brand that are covered by your health insurance or pharmacy benefit manager).
  • Check your health insurance’s website. Information on approved drugs and the process of step therapy is usually available online.
  • Your pharmacist will let you know. If there an approval process for the prescription, your pharmacist will be able to see this when processing your insurance. Then you can contact your doctor for:
    o Another prescription that doesn’t require an approval or
    o To get started on the approval – step therapy – process

Why Should I Bother?

If your specific prescription requires step therapy but you haven’t adhered to the process, it will cost you more. The drug may not be covered at all according to the details of your health plan. You’ll save by being proactive and following the approval process.
Remember, step therapy is there to help you find an effective prescription at the most affordable price point. Following the steps allows you to explore your options and find the best solution.

Have a Question About Step Therapy?

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