What Is Step Therapy in Medicare?

Shot of a happy senior couple walking along the pier using step therapy

Medicare is a federal health insurance program that provides coverage for millions of Americans aged 65 and older. Medicare is designed to provide access to affordable healthcare to older adults, but it is not without its limitations. One of those limitations is the use of step therapy. In this article, we will explore what step therapy in Medicare is, how it works, its pros and cons, and the appeals process.

How Does Step Therapy Work in Medicare?

Step therapy is a protocol that requires patients to try less expensive treatments before moving on to more costly treatments. The goal of step therapy is to save money by avoiding the use of expensive treatments when less expensive alternatives are available. The protocol is widely used by private insurance carriers, especially in Medicare Advantage (Part C) and Medicare Part D prescription drug plans.

For example, if a patient needs a specific drug to treat a medical condition, they may be required to try a lower-cost alternative first. If that alternative is ineffective, they may then be allowed to use the more expensive drug. This applies to both Part D and Part B medications.

This process is different from traditional Medicare (Parts A and B), which allows patients to use any treatment that their doctor prescribes without any restriction.

Pros and Cons of Step Therapy in Medicare

Like any healthcare protocol, step therapy has its pros and cons. Let’s take a closer look.

Advantages of Step Therapy

Cost Savings: The primary advantage of step therapy is cost casings. By requiring patients to try less expensive treatments first, the protocol can help reduce the cost of healthcare. This is especially important in Medicare, where the program is already underfunded, and costs are a concern for both patients and taxpayers.

Encourages the Use of Generic Drugs: Step therapy can also encourage the use of generic drugs. Generica drugs are usually less expensive than brand-name drugs and can be just as effective. In fact, the Food and Drug Administration (FDA) requires that generic medications have the same active ingredients and produce the same effects as their brand-name counterparts. By requiring patients to try a generic drug first, step therapy can help reduce the cost of healthcare while still providing effective treatment.

Couple sharing picnic using step therapy on Medicare
One of the primary disadvantages of step therapy is the delay in access to necessary treatments

Disadvantages of Step Therapy

Delay in Access to Necessary Treatments: One of the primary disadvantages of step therapy is the delay in access to necessary treatments. For patients with serious or chronic conditions, delaying access to the most effective treatments can have negative health consequences.

Interference with Doctor-Patient Relationship: Step therapy can also interfere with the doctor-patient relationship. Doctors may have to spend time explaining the step therapy protocol to their patients, and some patients may feel that their doctor’s hands are tied in terms of what treatments they can prescribe.

Appeals Process for Step Therapy in Medicare

Patients who are subject to step therapy have the right to appeal the decision. The appeals process can be complex, but patients should know that they have options.

To appeal a step therapy decision, patients can take the following steps:

  1. Contact their Medicare Part C or Part D plan and ask for an explanation of the step therapy protocol and why it was applied to their case.
  2. Discuss their concerns with their doctor and request a written statement outlining why they believe that a specific treatment is necessary.
  3. Submit a formal appeal to the plan in writing, including all relevant medical records and the doctor’s written statements.
  4. Request a review of the appeal.

It’s crucial to be informed about step therapy in Medicare, as it could impact your health and your wallet. By understanding the pros and cons of step therapy, patients can make informed decisions and work with their doctors to get the best possible healthcare.