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 people to try lower-cost medicines first, before an 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 provider and your insurer to get the best care possible.
How does step therapy work?
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 1 or more lower-cost medicines before they will cover a higher-priced medicine that your healthcare provider 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:
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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 provider prescribed.
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Delays your treatment. While you are taking the time to try the lower-tier medicines, you are not getting the treatment that you need.
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Can lead to health complications. The delays in getting the correct medicine needed for your condition may put your health at risk.
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Often affects people with complex conditions. Step therapy is often used for chronic or complex conditions that require certain medicines and treatment.
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Goes against what your healthcare provider advises. It’s stressful not to be able to use the medicine that your provider believes is best for you.
Your provider can help you work through the step therapy process or find other options if possible.
What conditions does step therapy often apply to?
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:
It’s important to work closely with your provider and your insurer to know how step therapy will affect you and your care.
How do you know if step therapy will affect your prescription?
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 provider prescribed, then:
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Talk with the pharmacist. Find out what the insurer told the pharmacy. You will likely have to get a first step medicine that your insurer requires.
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Talk with your healthcare provider. Let them know you were not 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.
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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.
How can you work with your healthcare provider?
It’s important to work closely with your healthcare provider. They can help you work through step therapy to get you the medicine and care that you need. Many times, your provider will know if a medicine is subject to step therapy. Your provider may have staff who can also work with your insurer to complete the preauthorization process. When meeting with your provider:
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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 provider.
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Keep good records. It’s helpful to keep a detailed paper or electronic file. This should have information about your condition and medicines such as:
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Ask questions about any new medicines that are prescribed. If your provider prescribes a new medicine, ask if they know if insurers are covering it.
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Ask about other medicine options. Be proactive. Ask your provider what other medicines they can suggest if your health insurer won’t approve this new medicine.
Other options
Your healthcare provider may also advise other ways to try to get the needed medicine, such as:
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Using prescription medicine coupons. You may be able to get coupons for the preferred medicine online or at your provider’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.
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Contacting your insurer about your case. Your provider 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 provider can let them know if these lower-tier medicines won’t meet your health needs.