Member: When I went to pick up my prescription, my pharmacist said it wasn’t covered right now because it’s part of a step therapy program. What does this mean? — Charlotte, St. Paul
What is step therapy?
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.
Though your doctor may have prescribed a specific medication, there may be other options that cost less and work just as well. For example, generic drugs may often have the same quality and strength as a brand name medication and will typically be less expensive.
“If the generic or other alternatives work well for you, that is good news because you will most likely pay less out of pocket for the medicine.”
How step therapy works
Your doctor prescribes a medication and you find out that it requires step therapy at the pharmacy, either you or your pharmacist should tell your doctor. It’s possible there’s a different drug they could prescribe that doesn’t require step therapy.
If that is not an option, then your doctor can work with you through the step therapy process. If the generic or other alternatives work well for you, that is good news because you will most likely pay less out of pocket for the medicine. If this is not an option, your doctor can submit a request to your Blue Cross health plan for an exception, which is called a “coverage determination." If approved, the requested medication would be covered ongoing.
If you have questions, please call the number on the back of your member ID card.
If you’d like to get a better idea of which prescriptions require step therapy, you can find your drug formulary at the Medicare plan documents page under your Medicare plan name.
View a list of Medicare Advantage Part B drugs that require step therapy (PDF)
