One way we make sure you get the safest, most effective and reasonably priced drug is by using programs like step therapy.
Step therapy is first trying other drugs before “stepping up” to drugs that cost more.This helps you save by using less costly drugs when it makes sense. In step therapy you may first need to try an alternative, often generic, before we'll cover some drugs prescribed by your doctor.
Step therapy programs are developed using Food and Drug Administration (FDA) guidelines, clinical evidence and research. They ensure you are taking appropriate and cost-effective medicines.
What it means for you
If you’re now taking a drug that’s included in our step therapy program, talk to your doctor to see which options work best for you. Your doctor can decide to write a new prescription or submit a written request to keep using your current medication.
How the step therapy program works
Here's an example:
1. You take a prescription to the pharmacy for a drug that requires step therapy. They enter the order into the claim system.
2. The claim system checks your history to see if you already had an order filled in that time period for the alternative drug.
3. If a claim for the alternative drug is found, the claim will be processed automatically.
4. If there is no history of a prescription filled for the alternative drug, the prescription claim is rejected.
5. The pharmacist can then either contact your doctor to see if the alternative drug is acceptable or have you contact your doctor.
6. Your doctor can then give you a prescription for the alternative drug. Or, if they strongly feel that the original drug prescribed will best treat your condition, then they can submit a step therapy authorization request. If the request meets specified clinical criteria, the originally prescribed drug will be covered.
7. A notice will be sent to both you and your doctor about whether the request has been approved or denied. The review takes about five to ten business days. Refer to the FAQ section of this site for any questions you have about this program.