What is Step Therapy in Medicare Part D?

Question: What is Step Therapy in Medicare Part D?

Answer: Step Therapy is a utilization management restriction that your Medicare Part D prescription drug plan can add to a prescription medication.  Step Therapy requires that you try a less-expensive medication before the drug plan will pay for another drug that your doctor may have originally prescribed.

On our Medicare prescription drug finder (Q1Rx.com), we use "S" to designate that the Medicare Part D plan requires Step Therapy for a particular medication.

According to the Centers for Medicare and Medicaid (CMS) "Step Therapy" is defined as:

When your Medicare Part D plan requires you to first try one (usually less-expensive) drug before the drug plan will pay for coverage of another (usually more-expensive) drug for that same medical condition.  For example, if Drug AA and Drug BB both treat your medical condition, your Medicare plan may require your doctor to prescribe Drug AA first.  If Drug AA does not effectively treat your condition or work for you, then the plan will then cover Drug BB.

(source: Medicare.gov)

The downside of Step Therapy is that the trial process can take several months before that you and your doctor find that a particular medication (such as our example Drug AA) does not work as well as another medication (such as example Drug BB),

The good news is that you can avoid Step Therapy by either:
(1) choosing a Medicare Part D plan that does not have the Step Therapy restriction for your medication or

(2) you can ask your Medicare Part D plan for a Formulary Exception so that you can be exempt from the Step Therapy restriction.

You can read more about the Formulary Exception process here:
https://q1medicare.com/PartD-DrugListExceptionAppealGrievance.php

You can click here for an example of our 2018 Drug Finder search showing a medication and the plans that have various utilization management restrictions (Quantity Limits, Step Therapy, Prior Authorization - such as: S Q:10
/30Days).

As reference, here is our Q1Rx.com Drug Finder key to Medicare Part D utilization management restrictions.

Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt)

• None - This drug does not fall under any drug utilization management controls.
• P - Prior Authorization -This drug is subject to prior authorization.
• S - Step Therapy -This drug is subject to step therapy.
• Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.