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What's step therapy and how does it work?

Who is this for?

Learn more about prescription drug and pharmacy coverage.

If your pharmacist said your prescription drug needs step therapy, learn what that means and what you need to do.

Just because something's expensive doesn't mean it's the best. If you're a smart shopper, you find an option that costs less and works just as well.

That's the idea behind step therapy. We use it to make sure you're getting the most effective and reasonably-priced drug available. It keeps costs down for everyone.

How it works

Step therapy is trying lower-priced medications before taking a step up to one that costs more. Here’s an example of step therapy:

  1. You take a generic drug to lower your cholesterol, but it's not working.
  2. Your doctor prescribes another medication, but it's still not working.
  3. Your doctor prescribes a different medication that works well. But it's more expensive. You find out that it requires step therapy.

Before your plan will cover the more expensive drug, we'll check to see if you've tried lower-priced drug options. In this case, you have.

If you don't follow the procedure for step therapy when it's required, the drug may cost you more, or may not be covered at all.

What if my prescription requires step therapy?

You or your pharmacist should tell your doctor. There may be another drug they can prescribe that doesn't require step therapy. If not, your doctor can contact our Pharmacy Help Desk to start the approval process and tell us the information we need.

You can also start the approval process yourself by filling out and sending in a coverage determination form.

How do I know if a prescription requires step therapy?

You can look in one of these documents. Start by finding your plan below. If you're using the formulary—the list of drugs your plan covers—look for an ST after the name of your prescription.

Tip: You can quickly find your drug in a PDF using these shortcuts. For Windows, type Ctrl+F. If you're a Mac user, type Command+F. A small window will pop up on the screen. Enter the name of the drug you’re looking for, and you'll see all the places it shows up.

If you need help finding your prescription in these documents, see How do I read a drug list?

Individual Plans Drug List / Formulary
Medicare Plus Blue℠ PPO plans:
Essential, Vitality and Signature

Prescription Blue℠ PDP Option A
Comprehensive Formulary (PDF)

Want more details?
Step Therapy Criteria (PDF)

Medicare Plus Blue PPO Assure

Prescription Blue PDP Option B
Comprehensive Formulary (PDF)

Want more details?
Step Therapy Criteria (PDF)
BCN Advantage℠ HMO and
HMO-POS plans

Comprehensive Formulary (PDF)

Want more details?
Step Therapy Criteria (PDF)

Group Plans
Drug List / Formulary
Medicare Plus Blue Group PPO

Prescription Blue Group PDP
Group Comprehensive Formulary (PDF)

Group Enhanced Comprehensive Formulary (PDF)

Want more details?
Step Therapy Criteria (PDF)
Medicare Plus Blue Group PPO:
Essential, Vitality and Signature plans
Comprehensive Formulary (PDF)

Want more details?
Step Therapy Criteria (PDF)
Medicare Plus Blue Group PPO Assure
Comprehensive Formulary (PDF)

Want more details?
Step Therapy Criteria (PDF)
BCN Advantage HMO-POS for Groups

Comprehensive Formulary (PDF)

Want more details?
Step Therapy Criteria (PDF)

Not sure what group plan you have or which drug list to use? Don't see yours listed here? Call the Customer Service number on the back of your Blues ID card and we'll help.

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Page Last Updated Wed Oct 08 16:28:02 EDT 2014