Patient Advocate Foundation (PAF) is a national 501 (c)(3) non-profit organization which provides case management services and financial aid to Americans with chronic, life threatening and debilitating illnesses.
Know Your Drug Formulary Restrictions: Step Therapy
Every drug formulary has a list of restrictions and limitations designed to help save you and your insurance company money. It is important that you know what the most common restrictions are and what they mean for you.
One of these restrictions is step therapy (sometimes seen as ST on drug formularies). Step therapy is a program required for some medications that means you only receive coverage for the drug prescribed after first trying an equally safe and effective drug that is much cheaper.
Here is a breakdown of how step therapy works:
You are prescribed a drug requiring step therapy by your physician.
You present this prescription to your pharmacist.
The pharmacist enters the prescription into a claim system.
The claim system will automatically look back at your claims history (typically 180 days) to see if you have had a prescription filled in that time for a qualifying alternative, lower-cost drug.
If an alternative drug prescription is found, that claim for the drug requiring step therapy will be approved.
If there is no history of an approved alternate drug, the claim will be denied because it hasn’t met the step therapy requirement.
You or the pharmacist can then contact your physician to see if an alternative drug is acceptable. Option 1: The physician can then provide a prescription for an alternative drug. Option 2: Or your physician can submit documentation along with an authorization request to your insurer to ask them for an exception if they feel
strongly that the original drug prescribed is the best treatment.
A notification will be sent to both you and your physician on whether the request has been approved or denied. This review typically takes between five and 10 business days.
It is important that you stay proactive and be aware of your drug formulary. If you have been prescribed a drug that requires step therapy, make sure your doctor knows about the restriction. By being aware of the requirement you can avoid lengthy delays at the pharmacy and get medicine you need.