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What Is Step Therapy In Medicare

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What Is Prescription Drug Step Therapy

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Have you ever been prescribed a medication only to find out that your insurance company wants to you try a less expensive drug first to see if it works? That’s known as step therapy, and it’s one of the ways that insurance companies keep costs down.

The idea is to ensure that patients are using the least expensivebut still effectivemedications available, rather than going straight to a higher-cost medication. Step therapy is sometimes referred to as a “fail first” protocol, in that the lower-cost medication has to fail to treat a patient’s condition before the insurer will pay for higher-cost drug therapy.

Although step therapy most commonly applies to specialty drugs, a Health Affairs analysis conducted in 2018 found significant variation from one plan to another in terms of how frequently step therapy is applied to coverage determinations.

When step therapy is required, the rules vary in terms of how many steps are required .

Step therapy can only be used when there are realistic lower-cost alternatives to the medication that the patient has been prescribed, and it’s most likely to be used when there are multiple alternatives available.

What Is The Monthly Premium For A Medicare Prescription Drug Plan

Premiums vary by plan. The national average monthly premium for a Prescription Drug Plan in 2019 is $33.19, though you may pay more or less depending on your plan, your income, and where you live.

If your modified adjusted gross income is over a certain threshold, you may have to pay a higher premium for your PDP, or whats known as a Part D income-related monthly adjustment amount . This calculation is based on what you reported on your tax return two years earlier. If you are subject to this adjustment, Social Security will contact you.

If you have undergone a significant life event, you can appeal your Part D-IRMAA charge with Social Security.

You can choose to have your Prescription Drug Plan premiums deducted from your monthly Social Security benefit check. Contact your plan to set up these deductions.

What Does Step Therapy Mean In Medicare Drug Coverage

Each Medicare Part D plan has a list of covered drugs that are called a formulary. Within every formulary, there are a set of rules applied to the prescription drugs covered by the plan. One of those rules is called step-therapy. If you get a prescription for a medication that has step-therapy rules, there is a process you will have to go through depending on the kind of drug you were prescribed . There can be several drugs that are therapeutically equivalent, which means they essentially do the same thing but may have slightly different ingredients. Think of buying a generic brand of ibuprofen vs. buying Motrin ibuprofen over the counter at a drug store. There are the same variations for prescription drugs as well. Step Therapy is a process that requires members to start with the most cost-effective drug and only move on to other, more expensive, or risky medications if necessary. The exact number of steps and requirements can vary depending on the drug.

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What Do You Do If Your Insurance Company Denies Coverage

If your insurance company denies coverage for the prescribed medication, you have a few options:

  • File an appeal: Ask your doctor for documentation, including medical notes and any records about your condition, including potentially adverse reactions to the recommended alternative medications. Send in those records to your insurance company with your appeal.
  • Ask for samples: If you need the medication right away and cant wait for an appeal, ask your doctor if he or she has any samples or manufacturers coupons for the drug. The coupons will get you a discount if you have to pay out of pocket.
  • Check with the manufacturer: Some pharmaceutical companies offer significant discounts if you pay a cash price for the medication rather than go through insurance. Others offer drug assistance programs for individuals who cant cover the cost of their medication. Look up the drug and see if it has a website. The manufacturer will often list any discount programs on the main page.
  • Use a prescription savings program: If your insurance doesnt cover the medication, try a prescription savings card like FamilyWize or GoodRx to lower its cost. On average, users save 45% on their prescriptions.

What Can Patients Do

2020 Medicare Dual Advantage Formulary

A number of states are stepping up to make a difference. In recent years, 19 states have passed laws that allow insurers and PBMs to continue to use step therapy, but add important patient protections that ensure it is used safely and appropriately. For example, some state laws ensure that patients can be exempted from step therapy requirements when medically appropriate. Some states also limit the amount of time that insurance companies or PBMs can wait before approving or denying an exemption request.

Patients can find out if their state has a policy that helps establish rules and limits for step therapy and educate themselves about what it covers. If their state doesn’t have such a policy, they can reach out to elected officials and voice their support for responsible step therapy practices that put patients first.

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Check Your Plans Formulary Carefully Before Enrolling

When you enroll in a Medicare Advantage plan for the first time, or if you are considering changing plans, be sure to understand if any plan you are thinking of joining follows step therapy guidelines.

To do so, check the plans formulary, which is the list of drugs they cover and the price tiers they are grouped into. Find the prescription or prescriptions you need, and if you see the code ST next to it or any other indication that it requires step therapy.

David Levine is an award-winning writer and editor whose work has been featured in the New York Times, New York Daily News, Sports Illustrated, American Heritage, U.S. News & World Report and others.

David has covered health, health insurance and health policy topics among many others since 2017. He earned a Bachelor’s Degree in English from the University of Rochester and currently lives in Albany, New York.

Which Drugs Are In Step Therapy

Medications that may typically be included as a part of step therapy are drugs used to treat the most common medical conditions, such as:

  • Allergies
  • Bladder problems
  • Acid reflux and heartburn

This is because these conditions are most likely to have generic drug options that work very well for the majority of patients and cost upwards of 85% less than their brand-name equivalents.

Drugs for many other health conditions are not required to follow step therapy.

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What If My Prescription Requires Step Therapy

You or your pharmacist should tell your doctor. There may be another drug they can prescribe that doesn’t require step therapy. If not, you can call the number on the back of your Blue Cross ID card to start the approval process and tell us the information we need.

You can also start the approval process by filling out and sending in a coverage determination form.

Therapy: Where Does It Go From Here

How to use Medicare.Gov: Step by step!

The rise in step therapy policies is primarily being driven by rising drug costs. Employer-sponsored health plans are growing more restrictive with coverage. Participants in Obama Care health care exchanges are also affected. Many patients have switched carriers, either by choice or because insurers have exited the exchanges. When they do, patients are told to restart their step therapy protocols.

For patients with serious illness, they and their doctors believe this policy is insane.

State laws restricting the practice of step therapy vary widely.

According to the National Patient Advocate Foundation, a nonprofit group, Indianas law is the most aggressive. It bars insurers from restarting the step-therapy sequence if you failed certain treatments with a previous insurer. For example, insurers must adjudicate appeals within three days.

Patients in other states will do well to review the step-therapy policies of prospective insurers before signing up. Larger insurers will often post lists of drugs that are subject to step-therapy restrictions. However, sometimes even those restrictions can vary based on a particular employers health plan, for instance.

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Therapy And Mental Health Parity

Mental health parity rules prevent insurers from using more restrictive coverage standards for mental health and substance abuse treatment than they use for medical/surgical treatment.

This includes step therapy rules, which means insurers cannot have stricter step therapy requirements for mental health treatment than they have for medical/surgical treatments.

What Is Medicare Part D And How Much Does It Cost

A Medicare Prescription Drug Plan , or Part D, is the part of Medicare that provides coverage for prescription medications. Anyone who is eligible for Original Medicare can sign up for one of these plans, which are offered by private companies approved by Medicare.

If you dont get a Prescription Drug Plan when you first become eligible and you dont have whats called creditable coverage from another source, you may be subject to a late enrollment penalty when you do eventually enroll.

You can either get a standalone Medicare Part D plan to add to your other Medicare coverage or you can enroll in an MAPD, a type of Medicare Advantage plan that includes prescription drug coverage.

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What Is Step Therapy And What Does It Mean For Patients

Medical doctors have years of training and expertise in their chosen field. And yet, when it comes to prescribing a medication, they often have to jump through hoops before their patients can get the medicine they recommended. One of those hoops is called a fail first or step therapy policy.

What Is The Coverage Gap Or Donut Hole

CMS: Medicare Advantage Can Use Step Therapy for Part B Drugs

Medicare Prescription Drug Plans have a coverage gap, also known as the donut hole. Once you have received a certain level of benefits from your plan, you enter a coverage reduction period, where you will face higher out-of-pocket costs until you qualify for catastrophic coverage.

To better understand the donut hole, consider this example of how your Prescription Drug Plan coverage changes as your drug spending increases.

Phase 1: Meeting your deductible

Many Prescription Drug Plans have a deductible. In most cases only for brand name drugs.

Until you hit your deductible, youll be paying for 100% of the costs of your drugs. The maximum PDP deductible in 2019 is $415, but yours could be lower.

Phase 2: Initial coverage

Once you meet your deductible, you are only responsible for copayments until your total drug costs reach $3,820 for 2019. Total drug costs include what you pay out-of-pocket and the amount your PDP covers.

Phase 3: Coverage gap

During this period of reduced coverage, youre responsible for a significant portion of your drug expenses. Youre stuck in the donut hole until your total out-of-pocket drug costs for the year reach $5,100 .

While youre in the coverage gap, you qualify for discounts, which are funded by drug companies and the federal government. In 2019, youll pay no more than 25% of the cost of covered brand-name drugs, and no more than 37% of the cost of generics.

Phase 4: Catastrophic Coverage

The expenses that dont count include:

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Help Me Choose A Plan

Answer a few questions and well find the best recommended plan for you.

In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B. This Step Therapy Program encourages Medicare Advantage members to try less costly, but just as effective, Part B drugs before the plan covers another drug. We give you the information you need to take care of your health.

The list of Part B drugs and Preferred Alternatives below are impacted by Horizon Blue Cross Blue Shield of New Jerseys Step Therapy program:

Requested Product Included in the program beginning
Avonex, Rebif, Betaseron, Extavia, Tysabri, Copaxone, Tysabri, Ocrevus, Tecfidera, Gilenya, Aubagio
For Multiple Sclerosis: Interferon beta , Copaxone For Crohns Disease: Immunosuppressants , TNF Antagonist

If you need to find a new doctor who participates in one of our networks, our Doctor & Hospital finder makes it easy to find a health care professional who matches your needs.

Prior Authorization And Step Therapy For Part B Drugs In Medicare Advantage

Guidance for Prior Authorization and Step Therapy for Part B Drugs in Medicare Advantage issued to replace the previous memo Prohibition on Imposing Mandatory Step Therapy for Access to Part B Drugs and Services,. It also provides new guidance for Medicare Advantage plans that may use step therapy for Part B drugs, beginning January 1, 2019, as part of a patient-centered care coordination program.

Issued by: Centers for Medicare & Medicaid Services

Issue Date: August 07, 2018

HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.


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What Is Step Therapy

Step therapy may sound like an exercise program, but it actually refers to managed care for prescription drug therapies and a process that healthcare insurers use to control prescription drugs costs.

Step therapy is also known as step protocol or a fail first requirement. It is implemented by prescription drug insurance providers by using the most cost-effective drugs for a given condition as a first try before stepping up to a more expensive or risky therapy.

How does step therapy work with Medicare Part D coverage?If you have a prescription drug plan that includes formulary drugs which are subject to step therapy, you may be required to first use a cheaper equivalent before being able to use the formulary drug which your healthcare provider originally prescribed.

This managed care program is used to help lower ever-increasing prescription drugs costs that burden healthcare insurance. While lowering costs, step therapy also aims to continue high quality healthcare for patients even though they are taking generic drugs in place of brand-name drugs.

If your preferred prescription drugs are subject to step therapy management, but you want to avoid being affected by this protocol, you can take the following actions:

You can submit your formulary exception and supporting statement to your plan provider either orally or in writing. If you do submit a verbal request, your provider may ask you to also submit your request in writing.

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Who is this for?

Blue Cross Blue Shield of Michigan and Blue Care Network members under age 65 with prescription drug coverage.

The first questions members ask us about prescription drugs is how we’re reducing costs.

One way we do that is through our step therapy program. It works to make sure you get the safest, most effective and reasonably-priced drug available.

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How To Take Action

Recently, many of the US states with laws allowing insurers and PBMs to use step therapy have incorporated patient protections to ensure the process is used safely and appropriately. Some state laws ensure that patients can be exempted from step therapy requirements when medically appropriate, while other states limit the amount of time that insurance companies or PBMs can wait before approving or denying an exemption request.

If you live in the US, explore whether your state has a policy in place to establish rules and limits for step therapy. If your state doesnt have this kind of policy, make your voice heard and contact your elected officials. Urge their support for responsible step therapy practices that put patients first.

This post was written by the Davis Phinney Foundation.

This post has been sponsored by Adamas.

Therapy Requirements For Medicare Outpatient Medications

Security Health Plan requires step therapy for people who are prescribed any of the drugs listed in the table below for the first time. Step therapy prior authorization will be managed through our specialty pharmacy medication partner, Magellan .

Step therapy is the process of trying lower-priced drugs before taking a step up to one that is more expensive, in an effort to reduce the cost of care.

Step Therapy will be required for the medications listed in the table below provided the following are met:

  • The requested product meets the definition of a Medicare outpatient drug AND
  • The proposed use of the requested product has been determined to be a medically accepted indication AND
  • The proposed use of the preferred alternative agent has been determined to be a medically accepted indication AND
  • The dose, frequency, and duration of use may not exceed the safety and efficacy data supporting the medically accepted indication AND
  • The patient is considered a new start to the non-preferred product

Requested Product

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How Does It Work

As an example, a physician prescribes a medication for a patient’s condition. That medication is on the drug formulary, but the insurance company requires the patient to first tryand failmedications the insurance company “prefers.” When this happens, the physician must then prove to the insurance company or PBM that those drugs didnt work in the past, in order for the patient to get coverage for the medication that the physician had originally prescribed.

The process can take weeks or even months. And if a patient switches to a new insurer, they may have to go through this process again, depending on the drug formulary and the insurance plan.

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