Medicare #StepTherapy Rules

Step Therapy

Step therapy is a type of prior authorization. With step therapy, in most cases, you must first try certain less expensive drugs that have been proven effective for most people with your condition before you can move up a “step” to a more expensive drug. For instance, your plan may require you to first try a generic prescription drug (if available), then a less expensive brand-name prescription drug on its drug list, before it will cover a similar, more expensive brand-name prescription drug. However, if you’ve already tried the similar, less expensive drugs and they didn’t work, or if your prescriber believes that your medical condition makes it medically necessary for you to be on the more expensive step-therapy prescription drug, he or she can contact your plan to ask for an exception. If your prescriber’s request is approved, your plan will cover the step-therapy prescription drug.

Coverage Rules

Example of step therapy: Step 1—Dr. Smith wants to prescribe a new sleeping pill to treat Mr. Mason’s occasional insomnia. There’s more than one type of sleeping pill available. Some of the drugs Dr. Smith considers prescribing are brand-name only prescription drugs. The plan rules require Mr. Mason to try the generic prescription drug zolpidem first. For most people, zolpidem works as well as brand-name prescription drugs. Step 2—If Mr. Mason takes zolpidem but has side effects, Dr. Smith can use that information to ask the plan to approve a brand-name drug. If approved, Mr. Mason’s Medicare drug plan will cover the brand-name drug for Mr. Mason.

Quantity Limits

For safety and cost reasons, plans may limit the amount of prescription drugs that they cover over a certain period of time. For example, most people prescribed a heartburn medication take 1 capsule per day for 4 weeks. Therefore, a plan may cover only an initial 30-day supply of the heartburn medication. Should you need more medication, you may need your prescriber’s help to provide more information to the plan to extend the prescription.

What if my plan won’t cover a prescription drug I need?

• Get a written explanation (called a “coverage determination”) from your Medicare drug plan if your plan won’t cover or pay for a certain prescription drug you need, or if you are asked to pay a higher share of the cost.
• Ask your Medicare drug plan for an exception (which is a type of coverage determination.) If you ask for an exception, your doctor or other prescriber must give your drug plan a supporting statement that explains the medical reason for the request (such as why similar drugs covered by your plan won’t work or may be harmful to you). You can ask for an exception for these reasons:–You or your prescriber believes you need a drug that isn’t on your drug plan’s list of covered drugs.–You or your prescriber believes that a coverage rule (such as step therapy) should be waived.–You believe you should get a non-preferred drug at a lower copayment because you can’t take any of the alternative drugs on your drug plan’s list of preferred drugs. You or your prescriber must contact your plan to ask for a coverage determination.
• If your network pharmacy can’t fill a prescription as written, the pharmacist will give or show you a notice that explains how to contact your Medicare drug plan so you can make your request. A standard request for a coverage determination (including an exception) should be made in writing (unless your plan accepts requests by phone). You or your prescriber can also call or write your plan for an expedited (fast) request.
• If you disagree with your Medicare drug plan’s coverage determination or exception decision, you have the right to appeal the decision. Your plan’s written decision will explain how to file an appeal. You should read this decision carefully, and call your plan if you have questions. For more information on Medicare appeal rights, view the booklet “Your Medicare Rights and Protections” by visiting