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Navigating Step Therapy: Part 2

On our last blog, we talked about a common approval process for prescription drugs: step therapy. Step therapy helps insurance provider’s and pharmacy benefit manger’s (PBM) members find an effective prescription at the most affordable price.

While step therapy benefits insurance companies, PBMs and their members, it’s a process you don’t necessarily want to repeat multiple times. Once you find a prescription that addresses your specific health issue, you’re able to focus on feeling better.

In some cases, patients have to repeat step therapy when they switch insurance providers or PBMs. While you may have already tried drugs A & B before finding that drug C is the prescription that works for you, your new insurance provider doesn’t have that trial and error documented.

As a new member, you might be expected to try drug A and then B as a part of step therapy before your insurance company or pharmacy benefits manager will approve drug C. But you’ve already done all that. You know drugs A & B won’t address your health needs. What do you do?

Step Therapy

1. Appeal

After you figure out that your new insurance provider or PBM requires you to go through step therapy, ask your doctor to appeal on your behalf. You’ll need to contact your doctor’s office and explain the situation. After your doctor submits a formal appeal, you’ll wait on the insurance company’s decision.

2. Revert or Pay

The time it takes the insurance provider or PBM to process an appeal depends on the specific company. Call and ask for an approximate timeframe to get an idea of how long you’ll be waiting for the decision.

While you’re waiting, you still need to take care of yourself and continue your treatments. Ask your doctor for options that won’t jeopardize your health. In some cases, you’ll need to revert to a “first-line drug” that doesn’t require approval and is covered by your health insurance.

If you’re unable or unwilling to revert, you’ll pay out-of-pocket for the prescription. Plan ahead and budget for these payments based on the timeline your insurance company gives for their appeal process.

3. Submit a Manual Claim to Your Pharmacy Benefit Manager

This is a way to seek reimbursement if you are paying out of pocket during the appeals process. Your pharmacy benefit manager will have instructions and information about filing a claim available on their website. Remember, not all plans allow for manual claims so be sure to double check with your insurance provider or PBM.

Have a Question? Leave a Comment!

Many companies will be switching insurance providers and pharmacy benefit managers in the New Year. If you have a question about your prescriptions or your step therapy during the transition, feel free to comment below.

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