Often referred to as “fail first,” step therapy is an insurance protocol that requires a plan beneficiary to try and fail on a less expensive, insurer-selected drug before the insurer will cover the drug prescribed by the beneficiary’s health care practitioner.
How does step therapy work for Medicare Advantage plans?
As part of the agency’s ongoing activities to deliver on President Trump’s promises outlined in his American Patients First Blueprint, CMS will provide Medicare Advantage plans the option of applying step therapy for physician-administered and other Part B drugs in a way that lowers costs and improves the quality of care for Medicare beneficiaries.
Do insurers require Step therapy?
Insurers will typically require step therapy for expensive, brand-name drugs that have affordable alternatives, but the actual list of drugs will differ plan to plan. Some examples of these drugs include Differin, Clarinex, Abilify, Fenoglide, Nexium, and Prilosec.
How can I avoid step therapy with Medicare Part D?
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.
Does your prescription drug need step therapy?
If your pharmacist said your prescription drug needs step therapy, learn what that means and what you need to do. Just because something's expensive doesn't mean it's the best. If you're a smart shopper, you find an option that costs less and works just as well.
What is step therapy criteria?
It requires patients to try one or more medications specified by the insurance company, typically a generic or lower cost medicine, to treat a health condition. Patients must then fail on the medication(s) before allowing a “step up” to another medicine that may be more expensive for the insurer.
What is step therapy process?
Step therapy is a program for people who take prescription drugs regularly to treat a medical condition, such as arthritis, asthma or high blood pressure. It allows you and your family to receive the affordable treatment you need and helps your organization continue with prescription-drug coverage.
What is step therapy exception?
A step therapy exception request is needed when the prescriber is requesting coverage of a drug that has “step therapy” or requires a person to try the most cost-effective medication(s) in a certain order before coverage of (or “stepping up to”) the less cost-effective medication is granted.
What is the difference between prior authorization and step therapy?
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. This practice is also known as “fail first” and can take weeks or months.
What is step therapy in Medicare?
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 an example of a step therapy?
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.
What is the Safe Step act?
To amend the Employee Retirement Income Security Act of 1974 to require a group health plan or health insurance coverage offered in connection with such a plan to provide an exceptions process for any medication step therapy protocol, and for other purposes. This Act may be cited as the “Safe Step Act”.
What is Aetna step therapy?
How step therapy works. One of these special requirements or coverage limits is known as step therapy, where we require a trial of a preferred drug to treat a medical condition before covering another non-preferred drug.
What is a Medicare exception?
Exceptions requests are granted when a plan sponsor determines that a requested drug is medically necessary for an enrollee. Therefore, an enrollee's prescriber must submit a supporting statement to the plan sponsor supporting the request.
Does Medicare have step therapy?
Effective January 1, 2019, 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.
Is Verquvo covered by insurance?
Medicare prescription drug plans typically list Verquvo on Tier 3 of their formulary. Generally, the higher the tier, the more you have to pay for the medication. Most plans have 5 tiers.
What is a step edit insurance?
Step edits are a mechanism designed by health insurers to control cost. Usually, but not always, this means that patients are expected to try cheaper drugs before trying more expensive drugs. In some cases, especially with generic medications, this is perfectly reasonable.
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 happens if a plan denies a beneficiary's request?
If a plan denies a beneficiary’s request, the beneficiary has the right to appeal and CMS will be monitoring appeals activity to ensure beneficiaries’ requests are appropriately evaluated. Plans are required to provide enrollees with a written notice of its determination and information on how to appeal the decision.
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.
What are MA plans subject to?
Additionally, MA plans are subject to penalties if they do not spend at least 85% of revenue on healthcare services and quality improving activities.
When is Medicare open enrollment?
First, beneficiaries will have the opportunity during the upcoming annual Medicare Open Enrollment period between October 15, 2018 and December 7, 2018, to choose which Medicare Advantage is the best for them, including the option to choose a plan that includes step therapy if one is available in their area.
Can MA step therapy be used for Part B?
Under this new policy, step therapy can only be applied to new prescriptions or administrations of Part B drugs for beneficiaries that are not actively receiving the affected medication. This means that no beneficiary currently receiving drugs under part B will have to change their medication.
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.
Why do we use step therapy?
That's the idea behind step therapy. We use it to make sure you're getting the most effective and reasonably-priced drug available. It keeps costs down for everyone.
What happens if you don't follow the procedure for step therapy?
If you don't follow the procedure for step therapy when it's required, the drug may cost you more, or may not be covered at all.
Can you prescribe a drug that doesn't require step therapy?
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.
Consumer Options
If you skipped the earlier steps, your current drug may cost more or may not be covered at all. But don't despair.
Check Your Plan Carefully
During the annual Medicare open enrollment period – from Oct. 15 to Dec. 7 – you can choose the Medicare Advantage plan that is best for you, so take time to review whether a plan you are considering includes step therapy for your particular medications.
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.
Why is Medicare Advantage required to pass savings on to beneficiaries?
The reason, according to CMS, is to introduce “much-needed competition and negotiation into the market … that will result in better deals and lower drug costs for patients.” That’s because the Medicare Advantage plans are required to pass their savings from this cost management program on to beneficiaries in lower copayments and coinsurance requirements.
How to check if a prescription is ST?
To do so, check the plan’s 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.
What happens if you don't get lower step drug coverage?
On the other hand, if your never tried the lower step drug options, your current drug may not be covered , or your plan may require a higher copayment.
Can you join Medicare Advantage at 65?
In this example, let’s consider you go on to join a Medicare Advantage plan when you turn 65. If the higher-step drugs you’re taking to treat your high cholesterol are part of your plan’s step therapy program, the plan will reach out to your doctor to confirm that you have tried a lower-priced drug. Because in this example you have already tried the lower-priced (lower step) drug and found it to be ineffective, the plan will cover the cost of your current higher-step drug.
What is the clinical basis for step therapy?
The clinical basis for step therapy is that some conditions can be treated with different but therapeutically equivalent medications and there is not a good way to predict if a particular medication will be more or less effective for any one individual.
How does step therapy work?
If you haven’t previously tried a step 1 therapy, the pharmacist will work with your doctor to get a different prescription or work with your doctor and insurance company to request coverage for the originally prescribed drug.
What is step therapy?
Step therapy is a program that requires patients to try a lower cost prescription drug that treats a given condition before “stepping up” to a similar-acting, but more expensive drug. Other names for step therapy are “step protocol” and “fail first requirements.”
Can you move step therapy from one insurance to another?
Step therapy can be disruptive when a consumer moves from one insurer to another. A consumer might have tried one or more step 1 therapies under one health plan only to move to another health plan that requires the consumer to start over – or has different classifications of step 1 and step 2 medications. In these cases, your doctor may need to work with your new insurance plan to get a prior authorization (also called a step therapy exception or coverage determination) to continue coverage for the drug therapy that has been working well for you.
What drugs require step therapy?
Some examples of these drugs include Differin , Clarinex, Abilify, Fenoglide, Nexium, and Prilosec.
What is a first choice drug?
First-choice drugs (also known as front-line or first-step drugs) — These are the generic and lower cost, brand-name drugs that you will need to try before your insurer will cover the more expensive drug.
What to do if your insurance denies you a drug?
Ask them about any backup documentation or medical notes that could help you prove your prescription is medically necessary.