Step Therapy Clause Samples
The Step Therapy clause establishes a process by which patients must try and fail one or more specified, typically less expensive, medications before coverage is provided for a more costly or alternative treatment. In practice, this means that an insurer may require a patient to use a generic drug or a preferred brand-name drug first, and only if these are ineffective or cause adverse effects will the insurer approve coverage for other medications. The core function of this clause is to control healthcare costs and promote the use of proven, cost-effective treatments before moving to newer or more expensive options.
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Step Therapy. In the event a prescription drug on the formulary that is not subject to step therapy is subsequently added to the list of prescription drugs that require step therapy, the change will not apply to a participant who has been prescribed the prescription drug at the time of the change.
Step Therapy. For new medications, after the ratification date of this agreement, members must try a front line medication (usually a generic medication) prior to receiving back up medication (usually a brand name medication).
Step Therapy. Certain drugs require step-therapy. This means that to receive coverage, you will need to try specific formulary drugs that are proven, safe and cost-effective medicine before using the drug that requires step-therapy. Your Provider will be required to submit documentation to obtain Approval for a drug requiring step-therapy. Your Provider can request to bypass step- therapy by requesting Prior Approval.
Step Therapy. The Contractor may implement step therapy for behavioral health medications used for treating anxiety, depression and ADHD disorders. The Contractor shall provide education and training for providers regarding the concept of step therapy. If the T/RBHA/behavioral health provider provides documentation to the Contractor that step therapy has already been completed for the conditions of anxiety, depression or ADHD, or that step therapy is medically contraindicated; the Contractor shall continue to provide the medication at the dosage at which the member has been stabilized by the behavioral health provider. In the event the PCP identifies a change in the member’s condition, the PCP may utilize step therapy until the member is stabilized for the condition of anxiety, depression or ADHD. The Contractor shall monitor PCPs to ensure that they prescribe medication at the dosage at which the member has been stabilized.
Step Therapy. Step therapy protocol means that a Covered Person may need to use one type of medication before another. The PBM monitors some Prescription Drugs to control utilization, to ensure that appropriate prescribing guidelines are followed, and to help Covered Persons access high quality yet cost effective Prescription Drugs. If a Provider decides that the monitored medication is needed the Precertification process is applied.
Step Therapy. The District shall provide the following prescription drug plan: Step therapy programs intervene and support appropriate use at the point of service through pre-established clinical criteria. Step therapy guides members and physicians into using first-line therapies when appropriate. Prior Authorization promotes clinically appropriate and cost- effective medications. It ensures that prescribed medications are being used for their appropriate indications. The Drug Quantity Management program ensures that the number of pills dispensed agree with the FDA-approved dosing guidelines and medical literature.