What is step therapy? How to get insurance to pay for your ‘nonpreferred’ medication

What is step therapy? How to get insurance to pay for your ‘nonpreferred’ medication

Have you ever gone to pick up a new prescription medication, only to be told your insurance plan won’t cover it until you try a different medication first? This requirement is an insurance limit known as step therapy.

Step-therapy limits can feel confusing and frustrating, especially when you have a valid prescription and are ready to start treatment. To help you navigate this process, GoodRx, a platform for medication savings, runs through what step therapy is, why insurance companies require it, and what to do if you’re denied coverage for your medication.

Key takeaways:

• Step therapy is a coverage limit used by insurance companies. It requires you to try a lower-cost or preferred medication before a prescribed treatment is covered.

• Step therapy is often required for brand-name, specialty, or newer medications when lower-cost options are available. If your prescription is denied coverage because of a step-therapy requirement, your prescriber can switch you to a step-one medication or ask for an exception.

• If coverage is still denied, you can file an appeal, ask about covered alternatives, or look for savings programs. Staying in close contact with your prescriber and insurance company can help keep things moving forward.

What is step therapy?

Step therapy is a type of prior authorization — a restriction insurance companies put in place to help determine whether or not they will pay for certain medications. Insurance companies use step therapy as a way to help control costs and avoid unnecessary or inappropriate medication use. But many people argue that step therapy may negatively affect your health and make it harder for you to get the medication you need.

As part of this process, insurance plans group medications into multiple tiers, or steps. The number of steps varies by insurance company, but two or three steps are common.

Medications in the lowest step (step one) are usually covered without any issues. Typically, step-one medications have the lowest costs, are a preferred treatment for a specific condition, or fulfill both criteria. They’re often medications that have a lower-cost generic available.

If you get a step-therapy rejection, it means that the medication you’ve been prescribed isn’t a step-one option. Before covering it, your insurance company will likely require proof that either:

• You can’t take a step-one medication due to contraindications or other issues.

• You tried a step-one medication and it didn’t work for you.

How does the step-therapy process typically work?

You likely won’t find out that your prescription requires step therapy until the pharmacy bills your insurance. Your pharmacist will receive a step-therapy rejection from your insurance company once they submit a claim for the medication. After that, they’ll work with you and your prescriber to find the right solution for you.

You’ll likely need to try a step-one medication. In this case, your prescriber will need to send a new prescription for the step-one medication to the pharmacy. Your pharmacist will likely reach out to your prescriber for the new prescription. But you can often help make the process go faster by reaching out to your prescriber directly as well.

What if a step-one medication isn’t right for you?

Sometimes, taking a step-one medication may not be the right choice for you. Perhaps you’ve already tried one and it wasn’t effective or caused a bad reaction. Or maybe there’s a contraindication that makes it an unsafe choice for you. In this case, your prescriber will need to provide evidence of why the medication isn’t appropriate and ask for an exception from your insurance company.

Keep in mind that this process will take place between your prescriber’s office and your insurance company. Your pharmacy staff will likely help facilitate communication between your prescriber and insurer. But the pharmacy doesn’t have any control over getting your medication approved. So the best way you can help is by staying in touch with your prescriber and insurance company to ensure everything is moving forward as needed.

What medications require step therapy?

There are several reasons why your insurance plan may require step therapy.

Most of the time, step-therapy requirements apply to expensive, brand-name medications that have lower-cost alternatives. Insurance plans generally prefer that you try a generic medication before they cover a brand-name medication. This is especially true if the two medications are similarly effective for your condition or belong to the same drug class.

Your plan may also require step therapy if you’re prescribed a medication that isn’t the first-choice treatment option for your condition. Plans generally prefer to cover medications that have the most evidence behind them.

Step therapy is also a common requirement for specialty medications and limited distribution drugs. These are often high-cost medications that are only available through certain pharmacies. Biologics, such as adalimumab (Humira), certolizumab (Cimzia), and eculizumab (Soliris), are common examples. Because these medications are generally expensive and used for specific types of conditions, insurance companies often require a step-therapy protocol for them.

Finally, step therapy is often enacted for newer, brand-name medications that treat common long-term conditions, such as high cholesterol or diabetes. Since these conditions have multiple treatment options, insurance plans will typically require you to try a lower-cost alternative before they’ll approve a newer, more expensive treatment.

How do you know if your prescription requires step therapy?

You can call your prescription insurance company directly or go to their website to access your plan’s preferred medication list. On this list, you’ll find information about specific medications. This includes whether they’re covered, if they require step therapy, and if there are quantity or refill limits.

However, it’s OK if you don’t research your medications ahead of time. As mentioned, your pharmacy staff can usually tell you if step therapy is required when they process a claim.

What can you do if you’re denied coverage for your medication?

Your insurance plan may still deny coverage for your medication after you’ve tried a step-one treatment or your prescriber has asked for an exception.

If this happens, you have a few options to choose from, including:

• Filing an appeal: If your insurer denies coverage, you may be able to file an appeal to dispute their decision. If you decide to appeal, one of the best ways to build your case is to get your prescriber’s input. Ask them about any documents or medical information that could help you prove that the medication is necessary.

• Trying a different medication: Ask your insurance company for a list of the medications they prefer over the one you were prescribed. Then, discuss these options with your prescriber to see if one is a good fit for your needs.

No matter what, make sure your prescriber knows if you’re unable to start taking a prescribed medication. Leaving your condition untreated can put you at risk for complications. Your prescriber and pharmacy team will work with you to help you find an affordable treatment option. So don’t hesitate to reach out to them for guidance.

The bottom line

Step therapy is a coverage limit used by insurance companies. It requires you to try a lower-cost or preferred medication before a prescribed treatment is covered. Step-therapy rules are often applied to brand-name, specialty, or newer medications when lower-cost options are available. If your prescription is denied coverage due to a step-therapy requirement, your prescriber can switch you to a step-one medication or request an exception if there isn’t another option that’s safe and effective for you.

If your insurance still refuses to cover your medication, you can file an appeal, ask about alternative medications, or look for savings programs to lower your costs. Staying in close contact with your prescriber and insurance plan can help speed up the process.

Most importantly, don’t ignore the issue, because untreated health conditions can lead to complications. Your healthcare team can help you find a safe, affordable treatment option.

This story was produced by GoodRx and reviewed and distributed by Stacker.