What is Step Therapy?

1. What is Step Therapy? Step therapy is when an insurance company or pharmacy benefit manager (PBM) requires a patient to try certain medications, which may be lower cost to them, without success before agreeing to cover a particular medication that the patient’s doctor prescribed As an example, a physician prescribes a medication for a patient's condition. That medication is on the drug formulary, but the insurance company requires the patient to first try and fail medications the insurance company "prefers." When this happens, the physician must then prove to the insurance company or PBM that those drugs didn’t work in the past, in order for the patient to get coverage for the medication that the physician had originally prescribed. The process can take weeks or even months. And if a patient switches to a new insurer, they may have to go through this process again, depending on the drug formulary and the insurance plan. Patients can find out if their state has a policy that helps establish rules and limits for step therapy and educate themselves about what it covers. If their state doesn't have such a policy, they can reach out to elected officials and voice their support for responsible step therapy practices that put patients first. Source: pfizer.com w w w . c a p i t a l b l u e m e d i c a r e . c o m