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. For instance, some plans may require you to first try a generic drug (if available), then a less expensive brand-name drug on their drug list, before you can get a similar, more expensive brand-name drug covered.
requires a patient to try one drug before having access to another; that is, a non-preferred drug may be used only after the preferred drug has been used and has not been effective.
A requirement that certain drugs be used only after preferred "first line" drugs have been tried and shown to be ineffective or inappropriate for safety reasons. Part D drug plans may use step therapy requirements as part of their drug utilization management programs.
When a new, expensive drug comes out, and there are less costly alternatives available, PBM's (formularies) may require step therapy or documented proof that the lower-cost alternatives were tried first, and failed before approving the more expensive drugs.
This is treatment that begins with less medicine and steps up until the condition is under control, PBM's (see PBM) may require step therapy or documented proof that the lower-cost alternatives were tried first, and failed before approving the more expensive drugs.
(Also known as "fail first") This requires that a patient fail on one or more preferred formulary drugs—generally lower price, or generic drugs—before a prescription will be filled for the non-preferred drug a physician has determined would be most appropriate/effective for the patient.
In some cases, plans require you to first try one drug before they will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, a plan may require your doctor to prescribe Drug A first. If Drug A does not work for you, then the plan will cover Drug B.
Drug plans may require an enrollee to try one drug before the plan will pay for another drug. Step therapy aims to control costs by requiring that enrollees use more common drugs which are usually less expensive. The process of beginning drug therapy for a medical condition with the most cost-effective and safest drug therapy and progressing to other more costly or risky therapy is called Step Therapy or Fail First Requirement. Progression to a new medication is predicated on the former medication failing to provide symptomatic relief or cure; hence “fail first.” Physicians and drug plans may disagree on the proper Step Therapy and patients are encouraged to become knowledgeable and decisive in agreeing to protocols. Also called “step protocol.
