A step therapy program is a “step” approach to providing drug coverage. It is designed to encourage the use of cost-effective prescription drugs when appropriate. This means that you may first need to try an alternative, typically a generic drug, before we will cover certain medications prescribed by your physician.
Step therapy programs are developed using Food and Drug Administration (FDA) guidelines, clinical evidence and research. They ensure that you are taking appropriate and cost-effective medications.
What it means for you
If you’re currently taking a drug that’s included in our step therapy program, please talk to your doctor. Together you can discuss which medication options are best for you. Your doctor can decide whether to write a new prescription or submit a written request for you to continue your current medication.
How the step therapy program works
Below is an example:
1. A member presents a prescription for a drug requiring step therapy at the pharmacy
2. The pharmacist enters the prescription information into the claim system
3. The claim is submitted for processing – the claims system automatically looks back at the member’s claims history to see if the member had a prescription filled in that time period for the alternative drug
4. If a claim for an alternative drug is found, the claim will automatically process
5. If there is no history of a prescription filled for an alternative drug, the prescription claim is rejected
6. The pharmacist can either contact the member’s physician to see if an alternative drug is acceptable or advise the member to contact his/her physician.
7. The physician can then provide a prescription for an alternative drug. If the physician strongly feels that the original drug prescribed will best treat the member’s condition, then they can submit a step therapy authorization request. If the request meets pre-specified clinical criteria, the originally prescribed drug will be covered.
8. A notification will be sent to both the member and physician on whether the request has been approved or denied. The review takes approximately five to ten business days.
Refer to the FAQ section of this site for any questions you may have about this program.