I climbed the 72 steps at the Philadelphia Museum of Art. You know, the ones Rocky Balboa climbs during the training montage in the iconic 1976 film. I did it because I love movies. I did it for fun, you could even say for my health. There are millions of people out there who are forced to climb steps even when doing so could be bad for their health. It’s called step therapy and this is what you need to know.

What Is Step Therapy?

Health care in the United States is expensive, more expensive per person than most developed countries. So it’s no surprise that insurance companies are doing what they can to keep costs down — that includes Medicare Advantage and Medicare Part D plans.

This is where step therapy comes into play. To decrease prescription drug spending, you start on a less expensive medication treatment before you take a step to a more costly one. The idea makes sense. There’s no need to jump to the most expensive brand-name medication you see on TV when an older, tried-and-true generic drug may be just as effective.

If the medication works and works well, everyone wins. The problem is when it doesn’t, and unfortunately, it doesn’t always work out. Arbitrary rules set by your insurance plan can make it difficult to take that next step.

Medicare Advantage plans can use step therapy for drugs covered by Part B or Part D.

Delays in Care

You have to fail treatment before you can move to the next step. But what constitutes treatment failure? The length of treatment required can vary from plan to plan. The suggested medications could be different too.

The problem is that some step therapy treatment durations do not align with what is recommended by professional medical organizations. To keep costs down, insurance companies may want to keep you on cheaper medications longer. This could lead to unnecessary delays in care, not to mention costly ED visits and hospital stays if symptoms get worse in the meantime.

Left untreated, some medical conditions can progress quickly, leaving you to develop preventable complications. In some cases, those complications could be irreversible and even life-threatening. Rheumatoid arthritis could spread to other joints. Inflammatory bowel disease could progress to colon cancer. Someone with bipolar disorder or another mental health condition could become suicidal. Waiting too long for effective treatment puts you in harm’s way.

Changing from a Stable Med

Some people may be forced to change their medication regimen when they go on a new plan. This can be counterproductive if you are doing well on your current medication, especially if there is any chance your condition could worsen during that time.

For example, one plan may require you to a fail a 6-month course of a certain treatment but your last plan only required you to try it for 3 months. In that case, you would need to go back and try it again even though you already know it’s unlikely to help. That’s another 3 months of ineffective treatment.

This is only one of many ways insurance companies can put obstacles in your way.

Thankfully, Medicare Advantage plans cannot use step therapy for Part B medications you are already taking. It only applies to new Part B prescriptions.

Changing Insurance Plans

If you are on a Medicare Advantage or Part D plan, you will get an Annual Notice of Change (ANOC) toward the end of the year, before the Medicare Open Enrollment Period (October 15 – December 7). Pay close attention to this. You must be notified if there will be any changes to your drug coverage. This also includes whether or not step therapy will be required in the coming year.

If you decide to change to a new plan, you will want to find out if the new plan uses step therapy for any medications you currently take. You can search Medicare’s Plan Compare site to get a quick look. They don’t make it easy for you though.

1. Enter your zip code and preferred plan type (Medicare Advantage or Part D). Click Start.
2. Enter whether or not you get assistance from any of the listed programs. Click Next.
3. Enter your current medications one by one. Click Done Adding Drugs.
4. Enter at least 1 preferred pharmacy. Click Done.
5. If you are considering Medicare Advantage plans, go to the filter for Drug Coverage. Select Includes Drug Coverage and click Apply. No filters are needed when searching Part D plans.
6. When you find a plan you are interested in, click Plan Details.
7. Scroll down and click on + View More Drug Coverage.
8. Look under Other Drug Information. You will see if your medication requires prior authorization, quantity limits, and/or step therapy.

The Medicare Plan Compare site does not provide you a way to see if a plan uses step therapy for medications you are not currently taking. You will need to reach out to the plan directly for that information.

What You Can Do

Choosing a plan that does not require step therapy is one way to save yourself some hassle. That said, it may be hard to find a plan that doesn’t use prior authorization or step therapy when more expensive drugs are involved. In those cases, you may need to apply for an Exception.

An Exception outlines the medical reasons you need to bypass step therapy to get started on a certain medication. This will require medical documentation and support from your healthcare provider. Any contraindications to therapies on the step therapy list can also be included here, i.e. allergies, an inability to access certain services on the step therapy list, partial treatment failures, the progressive nature of your disease, etc. According to the Centers for Medicare & Medicaid Services, your plan is required to give you an answer in 14 calendar days for standard cases, in 72 hours for expedited cases.

Congress is looking to help too. The Safe Step Act has bipartisan support and is expected to be introduced in the House later this year. The goal is to make it easier to get a Step Therapy Exception approved. In the meantime, you can check to see if there are any legal protections for step therapy in your state.

 

Anderson, K. E., Alexander, C., Ma, C., Dy, S. M., & MA. (2022). Medicare Advantage Coverage Restrictions for the Costliest Physician-Administered Drugs. AJMC, 28. https://www.ajmc.com/view/medicare-advantage-coverage-restrictions-for-the-costliest-physician-administered-drugs

How Does the U.S. Healthcare System Compare to Other Countries? (2022). Peter G. Peterson Foundation. https://www.pgpf.org/blog/2022/07/how-does-the-us-healthcare-system-compare-to-other-countries

H.R. 2163, Safe Step Act. 17th Congress 1st Session. (2021). https://www.congress.gov/117/bills/hr2163/BILLS-117hr2163ih.pdf

S. 464/H.R. 2163, Safe Step Act of 2021 Summary. (2022). Step Therapy. https://www.steptherapy.com/wp-content/uploads/2022/10/07-14-2022-Safe-Step-Act-Flyer.pdf

Step Therapy Legislation by State. (2023). Step Therapy. https://www.steptherapy.com/step-therapy-legislation-by-state/

Zimmerman, R. (2023). Need a new drug? You may be asked to “fail” an old drug first. The Washington Post. https://www.washingtonpost.com/wellness/2023/02/06/prior-authorization-fail-first-step-therapy/