Understanding Step Therapy and Why Health Plans Use it

Today | 4 min read

Key Takeaways

Step therapy requires trying safe, effective and lower-cost medications first before coverage is approved for certain higher-cost prescriptions.
Understanding step therapy requirements can help members avoid unexpected pharmacy delays, coverage issues and higher out-of-pocket medication costs.
If a prescribed medication doesn't work, doctors can explore alternatives or request a health plan exception for coverage.
Step therapy helps control prescription drug spending while maintaining access to clinically appropriate treatments supported by medical evidence.

Understanding health insurance can sometimes feel like learning a new language. Terms like deductibles, copays, prior authorization and step therapy determine how a health plan covers care and how much members pay out of pocket, so they are important to understand. More often than not, knowing how certain health insurance processes and protocols work saves you time, money and in step therapy’s case, confusion at the pharmacy.

When your doctor prescribes a medication, learning that your health plan requires you to try another treatment first can be frustrating. This requirement, called step therapy is designed to encourage the use of clinically appropriate, cost-effective medications while facilitating coverage of more expensive products, when needed.

For anyone prescribed a medication that requires step therapy, understanding how the process works can help avoid unexpected costs and delays.

How does step therapy work?

Typically, with step therapy, the process starts with a first-line medication, often a generic drug. If that medication does not provide the desired results, your primary care provider (PCP) may prescribe another option. If that medication also does not work, they may recommend a third treatment.

The goal is to start with medications that are considered safe, effective and more affordable before moving to higher-cost alternatives. Blue Cross Blue Shield of Michigan’s step therapy programs are designed to find effective medications supported by clinical evidence that may meet your needs at a lower cost.

Specific requirements vary by health plan and medication. If a prescription requires step therapy, a pharmacist may alert the member when the prescription is filled. The member can then work with their PCP to determine the next step. If you don't follow the procedure for step therapy, the drug may cost you more, or may not be covered at all.

Why is your insurer asking you to try step therapy?

Prescription drug costs can add up, particularly for people who take medications regularly. Choosing an effective medication that costs less can help reduce out-of-pocket expenses.

A newer or more expensive medication does not automatically deliver better results. Established treatments often have substantial research and experience supporting their effectiveness, safety and appropriate use.

We encourage members to understand their prescription drug benefits and use tools such as their plan’s drug list – or formulary – to determine whether a medication is covered and whether requirements such as step therapy apply.

Step therapy also reflects a broader approach to managing healthcare costs, which includes finding ways to maintain access to effective care while avoiding unnecessary expenses. At Blue Cross we work to lower costs without lowering the quality of care. This applies to anyone who needs prescription drugs, as generic medications can lower copays and overall costs for everyone paying premiums.

Thoughtfully designed step therapy aims to balance access to appropriate treatment with responsible use of healthcare dollars. This helps to preserve affordable coverage for all Blue Cross Blue shield members

What if a medication within the step therapy process doesn’t work?

If the first medication in a step-therapy process doesn’t work, the patient’s doctor can determine what to try next. Depending on the health plan, another medication may be available that doesn’t require step therapy.

If the medication prescribed is still the most appropriate option, the doctor can work with the health plan to request an exception, sometimes called a coverage determination. If the request is approved, the medication can be covered by the health plan.

Because step-therapy requirements vary by health plan and medication, it’s important to check the plan’s formulary or call the number on the back of the member ID card with questions.

Knowing how step therapy works can help members avoid surprises at the pharmacy, understand their options and potentially save money on prescription medications.

Learn more about what we are doing to lower prescription medications for our members – including our biosimilars program – by visiting bcbsm/mibluedaily.com/affordability.

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