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What is step therapy?
Step therapy means starting your treatment with less expensive prescription drugs before stepping up to drugs that cost more. The program is typically used when many clinically effective medications and treatment options are available.
Here’s how it works:
- You’ll try the step 1 preferred drug or drugs first.
- If the step 1 drug isn't effective, you’ll then try the step 2 drug. This means that if you don't try the step 1 drug or drugs first, then a step 2 drug won't be covered. In some cases, you may need to try more than one step 1 drug before a drug in step 2.
You and your doctor can use the following directions to request it.
How to request a step therapy exception
Your doctor can request an exception to step therapy if your current drug is the best clinical option for you. Work with them to follow these steps:
- Complete the Express Scripts Prior Authorization + General Request Form. Download this form or request a paper copy by calling our Pharmacist Help Desk at 1-800-922-1557.
Express Scripts Prior Authorization + General Request Form (PDF) - Fax your completed form to 1-877-251-5896. Please include all requested information, including:
- Which medications you’ve tried that didn’t work
- Dosages used
- Reason for failure (side effects, not effective, contraindicated, etc.)
- Why an exception is necessary (if applicable)
If approved, we'll provide coverage of the requested drug.
Step Therapy FAQs
Find answers to common questions about step therapy.
1 Behavioral health services must be approved by Optum Health, Medica's behavioral health network administrator.
2 Receiving prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon many factors, including your eligibility and terms and conditions of the policy on the date you received services.
3 If your attending provider believes that an expedited review is warranted or Medica concludes that a delay could seriously jeopardize your life, health, or ability to regain maximum function, we will inform both you and your provider of the decision as soon as possible but not later than 72 hours from the time of the initial request.