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What is step therapy?

Who is this for?

Michigan Health Insurance – Customer Service – Pharmacy

This information explains what it means if your doctor has prescribed a medication that requires step therapy.

There are hundreds of different medications, with more becoming available every day. One way Blue Cross Blue Shield of Michigan and Blue Care Network make sure you get the safest, most effective and reasonably-priced drug available is by using programs like step therapy.

What is step therapy?

Step therapy is trying other medications first before “stepping up” to drugs that cost more. To help keep costs down for everyone, we want to know that less expensive options don’t work before your plan will cover the drug. Here’s an example of step therapy:

  • You try an over-the-counter medication for your allergy, but it doesn’t control your symptoms.
  • Your doctor prescribes a prescription drug that still doesn’t give you relief.
  • A third medication that's more expensive works well, but requires step therapy.

In this case, your prescription is covered if you've tried the first choice drugs. If you haven't tried step therapy, the drug may cost you more, or may not be covered at all.

What do I need to do if my prescription requires step therapy?

If your drug needs approval, either you or your pharmacist will need to let your doctor know. They might switch your therapy to another drug that doesn’t require approval from the health plan. Or your doctor will contact our Pharmacy Help Desk to start the approval process and tell us the information we need.

How do I find out if my prescription requires step therapy?

Want to know if your prescription needs step therapy? You may be able to find out by logging in to your account at bcbsm.com. Just follow these steps:

  1. After you've logged in, hover over My Coverage in the blue bar at the top of the page.
  2. Select Medical from the drop down.
  3. Click Prescription Drugs in the left-hand column.
  4. Click the link for Price a drug and view additional benefit requirements. It will take you directly to Express Scripts (formerly Medco). You won't have to log in again.
  5. Enter the name of the drug and follow the instructions. You'll need to know the dosage and how often you'll be taking it.
  6. You'll get an alert if the medication needs a coverage review. This tells you step therapy may be required. Your doctor can ask for a coverage review by calling 1-800-437-3803.

You can also look on your plan’s drug list (a list of approved medications). On a regular drug list, your prescription needs step therapy if it has an ST after the name. Most plans also have a special list of drugs that require step therapy.

Blue Cross Blue Shield of Michigan (Traditional and PPO plans)

Blue Care Network (HMO) plans

Medicare

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