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:
- Enroll in a Medicare Part D plan that does not use the step therapy restriction for the medications you use. Before you sign up, ask the policy providers in your service area if your medications are restricted by step therapy.
- If your prescription drug plan does have the step therapy restriction in place, and your medications are on their list, you can ask your provider for a Formulary Exception. This exempts you from the restriction.
A formulary exception is a formal request you make directly to your Part D policy provider. It asks the plan to either cover non-formulary drugs, to change the specific restrictions placed on the drug (as is the case in step therapy), or to lower the cost-sharing amount of a drug that has been moved to a higher tier.
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.
Your written supporting statement can be submitted by using the Model Coverage Determination Request Form which is available on Medicare’s official website. In most cases, the insurance provider must approve your formulary exception if the drug is medically necessary and your healthcare provider is able to provide information that supports this fact.
One problem associated with using step therapy management for prescription drugs is that the process of fail first may take months. If you are prescribed a medication that is included in the protocol, be sure to discuss all your concerns with your physician. It is important that you do not forgo taking medications because of step therapy management. Your healthcare providers can give you the information and support you need in respect to step therapy and the medications you take.
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