What is step therapy and how does it impact drug coverage?

• A. A process requiring a lower-cost, preferred drug trial before approving a higher-cost drug
• B. A requirement to use brand-name drugs first
• C. A method to automatically approve all prescribed drugs
• D. A process to waive all co-pays for high-cost drugs

Answer: (D)

Step therapy is a prescription drug coverage approach where a plan requires trying a lower-cost, preferred medication before approving coverage for a higher-cost or non-preferred drug. The idea is to start with the most cost-effective option that is clinically appropriate, and only move to more expensive therapies if the initial medication is ineffective, not tolerated, or contraindicated. This shapes drug coverage by guiding the formulary and authorization process: the first-line, lower-cost drug is typically covered with standard copays, while access to the more expensive drug depends on documenting failure or intolerance to the initial option or obtaining an exception. It does not waive all co-pays or automatically approve every drug; exceptions can be granted if a physician provides justification, but the default pathway emphasizes stepping up to costlier therapies only when necessary.