What is step therapy and how might it affect drug coverage?

• A. A program requiring trying a lower-cost alternative before a more expensive drug is approved
• B. A process to escalate care with higher-cost drugs first
• C. A policy that guarantees coverage for brand-name drugs
• D. A method to bypass prior authorization in all cases

Answer: (A)

Step therapy is a cost-management approach used by prescription drug plans that requires trying a lower-cost, clinically appropriate medication before coverage will be approved for a more expensive one. The idea is to encourage cost-effective prescribing while still ensuring patients get effective treatment. In practice, if a clinician prescribes a high-cost therapy, the plan often won’t cover it unless the patient has tried and not benefited from the cheaper option or cannot take it due to intolerance or contraindication. In such cases, an exception or prior authorization can override the step if there’s a valid clinical reason. So, drug coverage becomes conditional on attempting the lower-cost option first, rather than automatically covering the more expensive drug.