Step Therapy & Medicare

What is Step Therapy?

Think of this like shopping for a new flat screen television for your house. You can go to one store and it might cost $300. If you are a smart shopper, you are going to check the price online or at other retailers. You might see if you can subscribe to their email and receive a coupon. This is like Step Therapy, which is utilized to ensure you are getting the best priced prescription on the market. 

Step Therapy is essentially trialing lower costed drug before stepping to the next level. For example, you start taking a prescription to lower your blood pressure. In the beginning, you do not see any positive results. You will then be prescribed to a higher costing medication. If that does not work, you will go the next level up. If this prescription is more expensive but produces positive results, you will be advised to try Step Therapy. Before your prescription drug plan covers the prescription, the carrier will have to verify if you have tried the less expensive options.

How does Medicare Part D and Step Therapy Coordinate?

It is important to note how your Medicare Part D plan coordinates with Step Therapy. If your plan includes "formulary drugs", you could be obligated to use the cheaper option (generic) before the formulary (brand name) that was initially prescribed. If you do not know what a formulary is, it is a list of generic and brand name prescription drugs covered by your health plan. If your preferred medications are subject to Step therapy, you can enroll in Part D plan that does not use the Step Therapy restriction. Be sure to ask local providers before enrolling if the drugs are restricted by Step Therapy. If the restriction is enforced and your drugs are on their list, ask for an exception to the formulary to allow you to be exempt. This can be submitted either in a written Statement to your provider or orally. 

How Can MWG Senior Services Help?

If you would like to talk with someone about enrolling in Medicare Part D or how we can be of assistance with your prescription drugs, be sure to call MWG Senior Services at (877) 759-5760 or email Our team of advisors are ready to answer any questions you might have.

Leave a comment

Please note, comments must be approved before they are published