What to Know About Step Therapy and How It Works

Under new rules outlined in the Trump administration’s American Patients First policy, the Centers for Medicare and Medicaid is now giving Medicare Advantage plans the option of applying step therapy for physician-administered and other Medicare Part B drugs beginning in 2019. The hope is that this option will lower drug costs and improve the quality of care for Medicare beneficiaries, CMS states.

Step therapy requires prior authorization for drugs that are prescribed for some medical conditions. The first “step” requires the doctor to start with the most preferred — and least expensive — drug available for that condition. If that drug doesn’t work, the doctor can take the next steps to other, more expensive therapies.

[See: 10 Things You Need to Know About Medicare.]

However, if you are already on medication for a condition as a new Medicare Advantage enrollee, you may be covered for the higher-priced option if you have already tried the lower-cost drug. For example, suppose you are being treated for high cholesterol. Your doctor has already tried two drugs on the lower steps but they didn’t work, so she put you on a more expensive medication that effectively treats your condition. Now you join a Medicare Advantage plan or change plans, and these drugs are part of that plan’s step therapy protocol. Before your plan will cover the more expensive drug, it will check with your doctor to see if you’ve tried lower-priced drug options. In this case, you have, so your current drug will most likely be covered.

Consumer Options

If you skipped the earlier steps, your current drug may cost more or may not be covered at all. But don’t despair. “The consumer does have vehicles to circumvent the lower-cost drug, but they have to jump through some hoops to do it,” says Chris Hakim, vice president of Medicare products for eHealth.com, an online marketplace for health insurance plans. If you are denied coverage, you (or your pharmacist) should notify your doctor, who may be able to prescribe a different drug that doesn’t require step therapy. “A lot of people don’t know they are on step therapy until they try to fill a prescription,” Hakim says. “The consumer should have their pharmacist call their doctor right then and there.”

If that’s not an option, you can appeal to your plan and ask for an expedited exception if you and your doctor believe you need direct access to a drug that would otherwise only be available after trying a lower-step drug. These exception requests will be completed as fast as your health condition requires, and at least within 72 hours, Hakim says.

[Read: Your Guide to Medicare Coverage.]

If your plan denies your request, you have the right to appeal. CMS says it will monitor appeals to ensure beneficiaries’ requests are appropriately evaluated. Plans are required to provide enrollees with a written notice of its determination and information on how to appeal the decision.

“If the physician is involved and willing to go to bat for the patient, they have to have all the evidence to provide to the plan. The pharmacist can assist with this, and there are a lot of forms that can take hours to fill out,” says Tatiana Fassieux, a consultant with California Health Advocates, a Medicare advocacy organization. “Our recommendation as consumer advocates is to never accept no for answer. Always dig deeper.”

Check Your Plan Carefully

During the annual Medicare open enrollment period — from Oct. 15 to Dec. 7 — you can choose the Medicare Advantage plan that is best for you, so take time to review whether a plan you are considering includes step therapy for your particular medications. You can find out if your Medicare plan requires step therapy by looking at that plan’s formulary, the list of drugs the plan covers and the price tiers they are covered under. Look for your prescription in the formulary — if there is an “ST” after it, that means it requires step therapy.

[Read: How to Avoid Medicare Scams.]

CMS rules state that if Medicare Advantage enrollees, including new enrollees, are not satisfied with their plan, they have an opportunity to make a one-time election to go to another Medicare Advantage plan or switch to Original Medicare from Jan. 1 through March 31 annually. Individuals using this opportunity to change their Medicare plan may make a coordinating adjustment to add or drop Part D coverage, CMS says.

Hakim says only a few categories of drugs typically fall under step therapy, including allergy, depression, acid reflux and some over-the-counter medicines. “This is where you are most likely run into these issues,” Hakim says. Thus, as his colleague Andrew Shea, vice president of Medicare products at eHealth, says, “the majority of drugs are not subject to step therapy. People shouldn’t be losing sleep at night over this.”

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What to Know About Step Therapy and How It Works originally appeared on usnews.com