Getting coverage authorization for certain medications from Medicare may require you to try a cheaper drug first. This is called “step therapy.”
Medicare Part D offers general prescription drug coverage, whereas Part B covers drugs you can’t take yourself.
Each Part D plan has a formulary and a list of covered drugs. The drug’s tier in the formulary determines its out-of-pocket cost — the higher the tier, the more expensive the drug. With Part B, Medicare should pay 20% of the cost once you meet your deductible.
That said, with both parts B and D, as well as Medicare Advantage (Part C) plans, certain drugs may require “step therapy” before approval. Read on to learn when “step therapy” applies, how the process works, and when you can get an exemption.
Step therapy is a health insurance process requiring you to try a less costly medication before you can be approved for coverage of a costlier one.
With Part D, you’ll usually be asked to try a drug that is generally effective for most people with your condition. Only after you’ve tried it will Medicare allow you to “step up” to the more expensive medication.
Examples of medications you may need to try first include generic or biosimilar versions of the drug you want or a less-expensive brand-name drug.
This process works similarly when it comes to Part B, which covers drugs that aren’t self-administered, like injections, and only certain oral chemotherapy drugs. Medicare may require you, for example, to try a drug covered under Part D before getting approved for a drug covered under Part B if the latter is more expensive.
In addition, because Part C plans offer the same benefits as Original Medicare (parts A and B), these plans may have a similar step therapy requirement. Whether or not your plan requires this depends on your specific plan and whether it includes prescription drug coverage.
In Medicare, you may need to get prior authorization before your plan will cover certain medications.
This is a process by which Medicare needs to approve coverage for your prescription medications before you can fill your prescription. Your doctor must typically submit documentation explaining why you must take the drug. In Medicare Part D, prior authorization is called “coverage determination.”
That said, step therapy is a specific type of prior authorization.
To determine whether you should try an alternative drug, Medicare may examine your medical history and factors like age, sex, diagnosis, and other medications you take. Medicare will then notify you or your doctor of this requirement.
What is an example of step therapy?
Here’s an example of how “step therapy” might work:
You live with high cholesterol, and your doctor wants to prescribe you Repatha (evolocumab) to lower your levels of LDL (low-density lipoprotein) cholesterol.
Step 1
Your Part D plan asks you to try a generic drug like simvastatin (Zocor) or atorvastatin (Lipitor) first. These drugs cost less and are considered effective for most patients.
Step 2
You experience severe side effects while on Lipitor, or your cholesterol level doesn’t go down sufficiently. Your doctor requests approval for Repatha, providing the necessary documentation.
Step 3
Your Part D plan approves your prescription for Repatha.
In some cases, doctors may predetermine that a certain medication won’t work for you based on your medical history. But, to get coverage for a more effective drug that costs more, you’ll still have to take the alternative drug first and demonstrate that it isn’t effective. This can result in treatment delays.
That said, the rules for every Part D plan are different, and it’s important to check your specific plan’s rules for drug approval.
If you believe you have a medical reason for taking a specific prescription medication, you or your doctor can contact your plan to request an exception to the step therapy process.
Typically, your doctor will need to provide a statement explaining why you must take the specific drug without trying out the cheaper alternative, such as that taking the less expensive drug could result in negative health effects.
If your request is approved, parts B or D will cover your requested drug. Similarly, with Part C plans, you can submit a request, which you can also appeal if denied. Typically Part C plans approve or deny requests for step therapy exemption within 72 hours.
Step therapy is a health insurance process where you must try a cheaper medication before getting coverage for a costlier one.
Depending on your plan and the drug you want, parts B, C, or D may require you to first take a generally effective drug, like a generic or biosimilar, before moving to a more expensive option.