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what is step therapy medicare

by Liana Huel PhD Published 2 years ago Updated 1 year ago
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Step Therapy is a utilization management restriction that your Medicare Part D prescription drug plan can add to a formulary medication. If you have a formulary drug subject to Step Therapy, you are required to try a less-expensive medication before the drug plan will pay for the formulary drug that your doctor may have originally prescribed.

Medicare Advantage plans may use step therapy for Medicare Part B-covered drugs. Step therapy is a utilization management tool that allows a plan to require an enrollee to try a different, less expensive drug that treats the same condition before it will cover a more expensive drug.

Full Answer

What is part B Step therapy?

May 24, 2020 · 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 …

How to start my Medicare?

Step therapy is trying lower-priced medications before taking a step up to one that costs more. Here’s an example of step therapy: You take a generic drug to lower your cholesterol, but it's not working. Your doctor prescribes another medication, but it's still not working. Your doctor prescribes a different medication that works well.

What is prescription drug step therapy?

Aug 07, 2018 · What is Step Therapy? Step therapy is a type of prior authorization for drugs that begins medication for a medical condition with the most preferred drug therapy and progresses to other therapies only if necessary, promoting better clinical decisions.

What is the definition of step therapy?

Step Therapy is a utilization management restriction that your Medicare Part D prescription drug plan can add to a formulary medication. If you have a formulary drug subject to Step Therapy, you are required to try a less-expensive medication before the drug plan will pay for the formulary drug that your doctor may have originally prescribed.

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How does step therapy work?

Step therapy applies to prescriptions you receive at your local pharmacy, as well as those you order through home delivery, so the same basic process applies. Your doctor may write a prescription for a first-line drug covered by your plan, or your doctor can request an override.

What is an example of a step therapy?

Here's an example of step therapy: You take a generic drug to lower your cholesterol, but it's not working. Your doctor prescribes another medication, but it's still not working. Your doctor prescribes a different medication that works well.Apr 18, 2018

What is the difference between prior authorization and step therapy programs?

Automation of prior authorization for medications is referred to as electronic prior authorization. Step therapy is an insurance protocol that requires patients to try one or more insurer-preferred medications prior to a physician recommendation.

What is a step therapy approval?

Step therapy is a type of prior authorization for drugs that begins medication for a medical condition with the most preferred drug therapy and progresses to other therapies only if necessary, promoting better clinical decisions.Aug 7, 2018

What is the Safe Step act?

Establishes a clear exemption process: The Safe Step Act requires insurers implement a clear and transparent process for a patient or physician to request an exception to a step therapy protocol.Mar 26, 2021

What is a PA request?

A prior authorization (PA), sometimes referred to as a “pre-authorization,” is a requirement from your health insurance company that your doctor obtain approval from your plan before it will cover the costs of a specific medicine, medical device or procedure.

What are the 4 phases of Medicare Part D coverage?

The Four Coverage Stages of Medicare's Part D ProgramStage 1. Annual Deductible.Stage 2. Initial Coverage.Stage 3. Coverage Gap.Stage 4. Catastrophic Coverage.Oct 1, 2021

What drugs are not covered by Medicare Part D?

Medicare does not cover:Drugs used to treat anorexia, weight loss, or weight gain. ... Fertility drugs.Drugs used for cosmetic purposes or hair growth. ... Drugs that are only for the relief of cold or cough symptoms.Drugs used to treat erectile dysfunction.More items...

What is step therapy prior authorization quantity limit?

For example, a person may be prescribed a medication to take two tablets per day, or 60 tablets per month. If the plan has a quantity limit of 30 tablets per month for that medication, your doctor or prescriber will need to work with the Medicare Prescription Drug Plan to get authorization for a higher quantity.

Does Medicare Part B pay for prescriptions?

Medicare Part B (Medical Insurance) includes limited drug coverage. It doesn't cover most drugs you get at the pharmacy. You'll need to join a Medicare drug plan or health plan with drug coverage to get Medicare coverage for prescription drugs for most chronic conditions, like high blood pressure.

What is the difference between Part B and Part D?

Medicare Part B only covers certain medications for some health conditions, while Part D offers a wider range of prescription coverage. Part B drugs are often administered by a health care provider (i.e. vaccines, injections, infusions, nebulizers, etc.), or through medical equipment at home.Oct 1, 2021

What are the drug tiers?

There are typically three or four tiers:Tier 1: Least expensive drug options, often generic drugs.Tier 2: Higher price generic and lower-price brand-name drugs.Tier 3: Mainly higher price brand-name drugs.Tier 4: Highest cost prescription drugs.

How it works

Step therapy is trying lower-priced medications before taking a step up to one that costs more. Here’s an example of step therapy:

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.

How do I know if a prescription requires step therapy?

Start by finding your plan's formulary here. If you're using the formulary—the list of drugs your plan covers—look for an ST after the name of your prescription.

When will Medicare start implementing step therapy?

Medicare Advantage (MA) plans will have the choice of implementing step therapy to manage Part B drugs, beginning January 1, 2019 as part of broader care coordination activities that include patient rewards and incentives. Currently, there are more than 20 million beneficiaries enrolled in MA plans.

What is step therapy?

Step therapy is a type of prior authorization for drugs that begins medication for a medical condition with the most preferred drug therapy and progresses to other therapies only if necessary, promoting better clinical decisions. For example, using step therapy plans could ensure that a senior who is newly diagnosed with a condition begin treatment ...

What is the CMS?

Today, the Centers for Medicare & Medicaid Services (CMS) introduced much-needed competition and negotiation into the market for physician-administered and other Part B medications that will result in better deals and lower drug costs for patients.

Does MA cover Part B?

MA plans will still be required to cover all medically necessary Part B drugs for beneficiaries. The beneficiary can ask the MA plan for an exception if they believe they need direct access to a drug that would otherwise only be available after trying an alternative drug.

What Is Step Therapy?

Step therapy is a system for obtaining prior authorization for drugs and helping plan beneficiaries get the best medication treatment at the lowest price possible. It mandates that drug treatments for a medical condition progress in steps.

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:

What About Pre-existing Conditions?

If you are already taking a more expensive medication for a certain health condition at the time you join a Medicare Advantage plan with drug coverage, you may still be covered for that drug if you have already tried the lower-cost, first step drug.

How does step therapy work?

How step therapy works. Your doctor prescribes a medication and you find out that it requires step therapy. If you’re at the pharmacy and told that your prescription requires step therapy, either you or your pharmacist should tell your doctor.

Why is step therapy important?

Step therapy is used to ensure you’re getting the most reasonably priced and most effective drug available. Step therapy encourages the use of lower-priced medications before “stepping up” to medications that cost more. This helps keep costs down for everyone.

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