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This is a term with which many of us are not familiar, but which represents a nightmare for us when it is applied to our health insurance claims.  So what does it mean and when is it applied?

Step therapy is a protocol used by insurance companies to determine whether a particular health plan will pay for a drug in a specific situation.  The carrier takes the responsibility of determining whether certain prescriptions are the most “cost effective” drug available for certain diagnoses.

Please understand that even if a particular drug is on the plan’s formulary does not mean that there will not be roadblocks. We all need to be aware not only what the cost of our particular drugs are before we pick them up at the pharmacy, but we also need to know if there are requirements we will need to fulfill before we can pick them up.

Even more, we need to educate ourselves on the Step Therapy requirements for specific drugs.  This set of rules applies to specific drugs that are either quite expensive or which need to be monitored for other reasons.  The rules appear pretty simple on the surface: the patient must show that certain similar prescriptions were attempted without success before the requested drug will be approved.  Often physician’s records are requested to show that two or more drugs in the same drug category were attempted and that they were either not successful or that they produced adverse symptoms.  So where is the problem?

There are drugs which have some frustrating side-effects and we want to jump from one to another to find the right one as efficiently as possible.  The insurance companies don’t seem to see the urgency the way we do and they can choose to withhold their approval.  Weight loss, nausea and dizziness are only three of the side effects of some drugs, all of which make continuation unbearable.  We feel that it is only reasonable that the insurance company would help us to minimize our trauma, yet often that is not what happens.

What can we do?

First, check to see if a drug we are taking or which we are considering has a Step Therapy requirement on the carrier’s drug list.  If it does, ask questions regarding the particular details of the requirement: what are the names of the drugs that can count toward qualification of the drug we want and how long we must have taken the other drugs.

Second, enlist the aid of our physician’s office to minimize the stress we will experience.  Doctors’ offices go through this on a regular basis and they can make the experience of dealing with the insurance carrier a lot easier.  Often there are requirements for physicians’ records and if the office is prepared for these requests less time is wasted.  Also, there are times that doctors are asked to interface with the insurance carrier’s prescription department so preparing them will produce more cooperation.

Third, keep records of all conversations as you go through the Step Therapy experience.  Names, dates and details of conversations can be very helpful as this process goes on.

Step Therapy can produce a lot of stress and frustration.  We at CDA Inc. have gone through this with many clients over the years.  Please let us know how we can help.