Unlocking Medicare Step Therapy: How It Affects Your Prescription Drug Coverage

Medicare coverage for certain prescription drugs may require you to try a more affordable medication before approving a costlier alternative. This process is known as “step therapy.”

Medicare Part D provides general prescription drug coverage, while Part B covers medications administered by healthcare professionals, such as injections and some oral chemotherapy drugs.

Each Part D plan includes a formulary—a list of covered drugs categorized into tiers that influence your out-of-pocket costs. Higher tiers typically mean higher expenses. For Part B drugs, Medicare generally covers 80% of the cost after you meet your deductible.

Step therapy can apply to Medicare Parts B, C (Medicare Advantage), and D plans. Understanding when and how step therapy is implemented will help you navigate your prescription drug coverage more effectively.

What Exactly Is Step Therapy in Medicare?

Step therapy is a protocol requiring patients to start treatment with a lower-cost medication proven effective for most individuals before progressing to more expensive options.

In Part D, this often means trying generic or biosimilar drugs before Medicare authorizes coverage for pricier brand-name medications.

Similarly, Part B may require trying a Part D-covered drug before approving a costlier Part B medication. Medicare Advantage (Part C) plans, which combine Parts A and B benefits and often include drug coverage, may also enforce step therapy based on their specific policies.

Learn more about Medicare Advantage prescription drug (MAPD) plans and how they handle step therapy requirements.

Step Therapy vs. Prior Authorization: What’s the Difference?

Prior authorization is a broader Medicare process where approval is needed before certain prescriptions are filled. Doctors must submit medical documentation justifying the medication's necessity.

Step therapy is a specialized form of prior authorization focusing on trying less expensive drugs first. Medicare evaluates factors like your medical history and current medications to determine if step therapy applies.

Step Therapy in Action: A Real-World Example

Imagine you have high cholesterol, and your doctor prescribes Repatha (evolocumab) to lower your LDL cholesterol.

Step 1: Your Part D plan requires you to try generic statins such as simvastatin (Zocor) or atorvastatin (Lipitor) first, which are more affordable and effective for many patients.

Step 2: If these medications cause severe side effects or fail to adequately reduce your cholesterol, your doctor submits documentation requesting approval for Repatha.

Step 3: Upon review, your Part D plan approves coverage for Repatha.

Although some doctors may anticipate a medication won’t work based on your history, Medicare generally requires you to attempt the lower-cost alternative first, which can delay access to more effective treatments.

Since step therapy rules vary among Part D plans, it’s crucial to review your specific plan’s policies regarding drug approvals.

When Can You Request a Step Therapy Exception?

If you have a valid medical reason to bypass step therapy, you or your healthcare provider can request an exception from your Medicare plan.

This typically involves your doctor submitting a statement detailing why the cheaper medication is unsuitable and could negatively impact your health.

If approved, Medicare Parts B or D will cover the requested drug. Similarly, Medicare Advantage (Part C) plans usually respond to exemption requests within 72 hours, and you have the right to appeal a denial.

Key Takeaway

Step therapy helps manage prescription drug costs by encouraging the use of effective, lower-cost medications before approving more expensive options.

Depending on your Medicare plan—Parts B, C, or D—you may need to try a generic or biosimilar drug first. Knowing your plan’s step therapy requirements and how to request exceptions can ensure you receive the most appropriate treatment without unnecessary delays.

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