Work Through "Step-Therapy" Rejections Efficiently

A new year will bring more step-therapy insurance rejections...to try to encourage use of lower-cost, yet effective, medications.

Payers will often require patients to try similar lower-cost therapy first...then "step up" to more expensive treatments if needed.

For example, some patients may need to try generic metoprolol before their insurance will cover brand-name Bystolic (nebivolol).

This practice makes sense for many medical conditions...since most low-cost generics work just as well as expensive brand-name drugs.

But it can lead to confusion or delays if not handled properly.

Use these tips to navigate through step-therapy rejections.

Read rejection messages closely...they'll often tell you what alternative meds will need to be tried first.

Be ready to send this info to prescribers...to minimize lapses in therapy. Get our fax letter, Suggestion to Switch Medication, to help your pharmacist recommend an alternative med.

Take care when relaying step-therapy rejections to patients. Avoid saying "Your insurance will only cover a cheaper drug"...the patient may assume the med they're being switched to may not work as well.

Instead say "Your insurance is recommending a medication that's less expensive but works just as well. We can contact your prescriber to approve the switch...and let you know when the new Rx is ready."

Contact the insurance company if the patient already tried the preferred med. Patients may have paid cash...or switched insurance payers...and the current plan may not have a record of it.

For more help with handling step-therapy and other insurance rejections, see our updated tech tutorial, Billing for Rx Drugs.

Key References

  • www.cms.gov/newsroom/fact-sheets/medicare-advantage-prior-authorization-and-step-therapy-part-b-drugs
  • www.cms.gov/Medicare/Health-Plans/HealthPlansGenInfo/Downloads/MA_Step_Therapy_HPMS_Memo_8_7_2018.pdf
  • www.asco.org/about-asco/press-center/news-releases/step-therapy-creates-barriers-care-medicare-advantage
Pharmacy Technician's Letter. Jan 2019, No. 350113



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