Definition
What Is Step Therapy?
Last updated
Step therapy is a type of prior authorization that requires you to first try a specific, usually less expensive drug on your plan's formulary before the plan will cover a different, usually more expensive drug for the same medical condition. If the first drug doesn't work or isn't appropriate for you, your doctor can request that the plan cover the next step, the originally prescribed medication.
How it affects what you pay
Step therapy exists largely to manage cost, by requiring lower-cost options to be tried first (Medicare.gov, Drug plan rules). If your plan requires step therapy for a drug your doctor originally prescribed, you may need to fill and try a different, cheaper drug first, which can delay access to the originally intended medication but generally results in a lower initial copay. If the first-step drug fails to work for you, your plan can approve coverage of the next step once your doctor documents that outcome, at which point your normal copay or coinsurance for that drug applies.
Example
Consider a hypothetical: a doctor initially prescribes a newer, more expensive brand-name drug for a chronic condition. The insurance plan's step therapy rule requires the patient try a specific generic drug from the same class first. If that generic is not effective, the doctor documents this, and the plan then covers the originally prescribed brand-name drug. This is a general illustration, not medical guidance for any specific condition.
Why plans use step therapy
CMS has described step therapy as beginning treatment with the most preferred drug therapy and progressing to other therapies only if necessary, framing it as a tool intended to promote cost-effective clinical decisions (CMS, Medicare Advantage Prior Authorization and Step Therapy for Part B Drugs). Step therapy requirements are typically listed directly on your plan's formulary, alongside other utilization tools like standard prior authorization. See our guide on step therapy: when insurance requires you to try cheaper drugs first for a full walkthrough of the exception request process.
What to do if step therapy delays your treatment
Ask your doctor whether a step therapy exception is appropriate for your situation, since plans generally have a process for expediting review when a delay could be harmful. While that's being resolved, compare prescription prices on BetterBuyRx to see what the cash price for your originally prescribed drug looks like, in case you need a short-term option while the exception request is reviewed.
Checking your plan's step therapy rules
Search your medication on BetterBuyRx and check your plan's formulary document to see whether a specific prescription is subject to step therapy before your appointment, so you and your doctor can plan ahead for the process.
Frequently asked questions
Is step therapy the same as prior authorization?
Step therapy is a specific type of prior authorization. It requires you to try a less expensive, plan-preferred drug first before the plan will cover a more expensive alternative for the same condition.
What happens if the first drug in a step therapy protocol doesn't work for me?
Your doctor documents that the first drug wasn't effective or wasn't appropriate for you, and submits that to your plan, which can then approve coverage of the next step, the originally prescribed, more expensive drug.
Can I skip step therapy if my doctor thinks the first drug is not right for me?
You can ask your doctor to request a step therapy exception, providing clinical justification, which your plan will review before deciding whether to approve the originally prescribed drug without requiring the first step.
Sources
Compare prices & find savings
This page is for cost and savings education only. It is not medical advice. Talk to your doctor or pharmacist about your specific medications and coverage. Prices vary by pharmacy, location, quantity, and eligibility.
Related terms & guides
- Step Therapy: When Insurance Requires You to Try Cheaper Drugs First
Learn how step therapy works, why insurers use it, and how to request an exception if the required first-step drug is not right for you.
- What Is Prior Authorization?
Prior authorization definition: why insurance requires pre-approval for some prescriptions, how the process works, and what to do about delays.
- What Is a Formulary?
Formulary definition: what a drug list is, how tiers set your copay, and what to do if your medication isn't on your plan's formulary.