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If a health plan uses step therapy for certain drugs, it means that a patient can be required to try a lower cost prescription drug that treats a given condition before “stepping up” to a similar-acting, but more expensive drug. The health plan won’t cover the more expensive drug until the lower-cost medication has failed to treat the patient’s condition. Other names for step therapy are “step protocol” and “fail first requirements.”
Step therapy is a very common cost-control strategy. Step therapy generally saves money for both the patient and the health plan.
The clinical basis for step therapy is that some conditions can be treated with different but therapeutically equivalent medications and there is not a good way to predict if a particular medication will be more or less effective for any one individual.
In those cases, it is more cost-effective to start with a “step 1” drug – a generic drug or lower-cost or preferred brand-name drug – before trying a more expensive or non-preferred drug. Step 1 drugs are on a lower tier of a formulary, so the consumer pays a lower copay.
For the health plan, the base price (or ingredient cost) is typically lower for a low-tier vs. high-tier drug. Drug tiering and preferred/non-preferred status can also depend on the rebates that the health plan’s pharmacy benefits manager receives from the drug manufacturer.
Step therapy can be disruptive when a consumer moves from one insurer to another. A consumer might have tried one or more step 1 therapies under one health plan only to move to another health plan that requires the consumer to start over – or has different classifications of step 1 and step 2 medications. In these cases, your doctor may need to work with your new insurance plan to get a prior authorization (also called a step therapy exception or coverage determination) to continue coverage for the drug therapy that has been working well for you.
If your new prescription requires step therapy, the pharmacy looks back at your drug history to see if you’ve tried the step 1 therapy within a given time period. If you have, the pharmacy fills the prescription as usual. If you haven’t previously tried a step 1 therapy, the pharmacist will work with your doctor to get a different prescription or work with your doctor and insurance company to request coverage for the originally prescribed drug.
Prescription discount plans are NOT insurance plans. Discount plans are offered by drug manufacturers, drug stores and membership organizations like AARP.
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