Step Therapy

What Is Step Therapy?

Step therapy helps people treat medical conditions with prescription medications by first using generic drugs to treat the conditions and moving to brand-name or higher-cost medications only if the generic medications are not effective.

Generic Medications

Generic medications act exactly the same way in the body as brand-name medications, but they are much less expensive. Using generics helps you, as a health plan member, to save money and still receive the medications you need for your health.

Generic medications are accessible through a list of medications approved by your health plan, called a "formulary." Drugs in a formulary are categorized on different levels — or tiers. The lower the tier, the lower the cost (copayment) of the medication to the health plan member; the higher the tier, the higher the cost (copayment) of the drug.

By placing generics on the lowest copayment level, you have the ability to save money and still receive quality medications. If your benefit plan is a Health Savings Account (HSA) or a High Deductible Health Plan (HDHP), a generic medication will be less expensive than a brand name alternative.

Generics And Step Therapy

Using generic medications is one way to save money, but many members either have prescriptions for brand-name drugs for the treatment of chronic medical conditions, or are prescribed a brandname drug for a sudden onset of illness. With step therapy, members work with their doctors to start a medication, beginning with the most cost-effective and safest drug available and progressing to other, more costly therapies only if necessary.

With step therapy, only medications are used that are very similar and can be interchanged easily. This way, you can find the best medication for your needs with the least cost. If a medication doesn’t seem to be working, you can “step up” to a similar medication in the next level in the approved drug list, but you may pay more.

Your formulary may have step therapy in the following drug classes:

  • ACE-inhibitors/angiotensin receptor blockers for high blood pressure
  • Non-steroidal anti-inflammatory drugs
  • Bisphosphonates for osteoporosis
  • Selective serotonin agents for depression
  • Triptans for migraines
  • Nasal antihistamines for allergies
  • Overactive bladder medications
  • Benign Prostatic Hypertrophy (BPH) medications
  • Eye drops for glaucoma
  • Acne medications
  • Proton Pump Inhibitors for acid reflux
  • Antipsychotic medications
  • Nasal steroids
  • Sleep medications

Step therapy looks at therapeutic equivalents, not chemical equivalents. That means a drug acts very similar — if not the same — in the body. Your doctor will work with you to find a new medication if step therapy is required.

If you are asked to try step therapy the next time you are prescribed a medication, you can be sure it is one way of helping you find the most cost-effective, quality treatment for your condition. The use of step therapy is based on the latest medical findings, the U.S. Food and Drug Administration’s medication labeling and medication costs.

Considering that the average cost of a brand-name medication is $335, compared to $22 for a generic medication, step therapy is a good “step” toward taking care of your health — and your pocketbook.