Step therapy drug program

One way we make sure you get the safest, most effective and reasonably priced drug is by using programs like step therapy.

Step therapy is a process that requires trying another drug that may be more safe, clinically effective and, in some cases, less expensive, before a more expensive drug is approved. This helps keep costs down for everyone.

What is step therapy?

Sometimes there's more than one drug that works to treat a medical condition. For example, for some drugs, if your doctor prescribes one that has an FDA-approved generic alternative, you may first need to try it before we will cover the non-generic version.

Step therapy uses a “step” approach for covering prescription drugs to encourage using clinically appropriate and/or lower-cost drugs. Step therapy programs are developed using Food and Drug Administration (FDA) guidelines, clinical evidence and research. 

Your doctor can decide 

If you’re taking a drug that’s included in our step therapy program, talk to your doctor to see which options work best for you.

Your doctor can decide to:

• Write a new prescription for an alternative drug that's covered.
• Ask for an exception so you can have coverage for your current drug. Your doctor can use one of the exception forms below to request an "override" of the program.

How it works 

You take a prescription for a drug that requires step therapy to the pharmacy.

• If you’ve had a prescription filled for an alternative drug through Prime Therapeutics, the claim is processed automatically.
• If you haven’t, you or your pharmacist can contact your doctor to see if an alternative drug is acceptable.
  • If it is acceptable, your doctor can give you a prescription for the alternative drug. Or, if they feel that the originally prescribed drug is needed, they can request an exception/override.
  • Most requests will be reviewed within three business days. You and your doctor will receive a notice about whether it’s approved or denied.
  • If the originally prescribed drug meets specific clinical criteria, the exception request is approved and the originally prescribed drug will be covered. If it’s not approved and you want to continue using the drug, you will need to pay for the drug yourself. 

Covered drug lists and step therapy

Whether a drug is part of a step therapy program may depend on your covered drug list (different health plans have different covered drug lists). Many of our covered drug lists work with step therapy, including all GenRx and KeyRX drug lists. If you have the FlexRx drug list, step therapy programs vary depending on your health plan.

Search a covered drug list. (You’ll need to know the name of your formulary and choose it from a dropdown menu for this search. You can find your formulary name in your health plan materials or by calling the customer service number on your member ID card.) Note: Lists may change without notice.

Prior authorization: A process to ensure appropriate prescribing and use before a drug will be covered. Coverage may be approved after certain criteria are met. Learn about prior authorization for prescription drugs.

Request an exception so your drug is covered

Complete an online form:

You or your doctor may complete this online exception form to request coverage for your originally prescribed drug.

Drug coverage exception form (online)

OR

Print, complete and fax or mail a form:

Your doctor can complete this form and fax or mail it to the contact information on the form.

Download step therapy prior authorization request form.