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 medical condition before you can move up a “step” to a more expensive drug. For instance, your plan may require you to first try a generic prescription drug (if available), then a less expensive brand-name prescription drug on the formulary, before it will cover a similar, more expensive brand-name prescription drug. However, if you’ve already tried the similar, less expensive drugs and they didn’t work, or if your prescriber believes your medical condition makes it medically necessary for you to be on the more expensive step-therapy prescription drug, he or she can contact us to ask for an exception. If your prescriber’s request is approved, the plan will cover the step-therapy prescription drug.
Step 1: Dr. Jones wants to prescribe a new sleeping pill to treat Mr. Brown’s occasional insomnia. There’s more than one type of sleeping pill available. Some of the drugs Dr. Jones considers prescribing are brand-name only prescription drugs. The plan rules require Mr. Brown to try the generic prescription drug zolpidem first. For most people, zolpidem works as well as brand-name prescription drugs.
Step 2: If Mr. Brown takes zolpidem but has side effects, Dr. Jones can use that information to ask the plan to approve a brand-name drug. If approved, Mr. Brown’s plan will cover the brand-name drug for Mr. Brown.
Coverage of drugs is first determined by your pharmacy or medical benefit. Please refer to your Evidence of Coverage for information about your benefits.
|Drug name||Step therapy criteria||Drug that must be tried first|
|Maxalt and Maxalt-MLT, naratriptan, rizaptriptan, and Zomig and Zomig ZMT||Requiring prior therapy with generic sumatriptan||sumatriptan|
|Vibryd, Pristiq, Marplan||Requiring prior therapy with any two of the following drugs: fluoxetine, paroxetine, citalopram, escitalopram, sertraline, venlafaxine, or bupropion||fluoxetine, paroxetine, citalopram, escitalopram, sertraline, venlafaxine, or bupropion|
|Benicar and Benicar HCT||Requiring prior therapy with generic losartan||losartan|
|Uloric||Requiring prior therapy with generic allopurinol||allopurinol|
|Fanapt, Fazaclo, Latuda, Risperdal Consta, Saphris, Seroquel XR||Requiring prior therapy with any two of the following drugs: clozapine, olanzapine, risperidone, quetiapine, ziprasidone||clozapine, olanzapine, risperidone, quetiapine, ziprasidone|
|Celebrex||Requiring prior therapy with generic meloxicam||meloxicam|
|Renagel and Renvela||Requiring prior therapy with generic calcium acetate||calcium acetate|
|Zolinza||Requiring prior therapy with generic fluconazole, ketoconazole||fluconazole, ketaconazole|
Y0089_EL3985FH CMS Approved 05/20/2014
Last updated: 05/20/2014