Understanding Step Therapy

May 3, 2018

What is Step Therapy?

Step therapy ensures you get the safest, most effective and reasonably-priced drug available. Step therapy means trying less expensive options before “stepping up” to drugs that cost more.

Do More Expensive Drugs Work Better?

A higher cost does not mean that a drug is better. A brand name drug may have a less-expensive generic or therapeutic alternative that might be an option for you. Generic and brand name drugs must meet the same standards set by the U.S. Food and Drug Administration for safety and effectiveness. Work with your doctor to determine which medication options are best for you.

What If My Doctor Insists that I Use a Brand Name Drug?

When possible, your doctor should prescribe a first-line medication appropriate for your condition.

If your doctor determines that a first-line drug is not appropriate for you or is not effective in treating your condition, your prescription drug benefit may cover a second-line drug when certain criteria are met.

How Does Step Therapy Work?

With step therapy, you may be asked to first try a “first-line” medication, which is normally a less expensive generic drug that is recognized as safe and effective in treating a specific medical condition. In this case, you will need to try the “first-line” medication before your benefit plan will cover a “second-line” drug which is a less preferred or potentially more costly treatment option.

How Do I Know If My Medication is Part of the Step Therapy Program?

View the most current Blue KC Prescription Drug List and the medications that require step therapy:

  • Log into MyBlueKC.com.
    If this is your first time logging in, you will need your Blue KC member ID card to reference.
  • Click Pharmacy at the top.
  • Click Prescription Drug List on the left.
  • Once the file opens, scroll to find your medication(s).
  • Any medication listed with ST under the column “Restrictions/Limits” will require step therapy.
  • Any medication with 2ST requires the trial of at least two preferred alternatives first.

How Does My Prescription Coverage Work?

Review your prescription drug benefit to determine if the medication you are taking is included. If you are taking a medication that is part of the step therapy program, your coverage may be impacted.

If you start taking a medication that is included in the step therapy program after the program becomes part of your prescription drug benefit, your physician will need to write you a prescription for a first-line medication or submit a prior authorization request for your current prescription before you can continue to receive coverage for the drug.