Step Therapy Program

Step therapy

Step therapy programs are developed using Food and Drug Administration (FDA) guidelines, clinical evidence and research. A step therapy program is a "step" approach to providing drug coverage. It is designed to encourage the use of cost-effective prescription drugs when appropriate. This means that you may first need to try an alternative, typically a generic drug, before we will cover certain medications prescribed by your doctor.

The standard step therapy drug categories include:

  • Antidepressants, used to treat depression
  • Cholesterol lowering medications
  • Diabetic meters and strips
  • Proton pump inhibitors, used to reduce production of stomach acid

What it means for you

If you're currently taking a drug that’s included in our step therapy program, please talk to your doctor. Together you can discuss which medication options are best for you. Your doctor can determine whether to write a new prescription or submit a written request for you to continue your current medication.

How the step therapy program works

Present your prescription for a drug requiring step therapy (Drug B) at the pharmacy.

  • The pharmacist enters the prescription information into their system
  • If you had a prescription filled for the prerequisite drug (Drug A) in the past 90 days, your prescription will be covered under your benefits
  • If there is no history of a prescription being filled for Drug A, the pharmacist can either contact your physician to see if Drug A or another alternative is acceptable or advise you to contact your physician
  • If the physician strongly feels that Drug B will best treat your condition, they can submit a step therapy authorization request. Drug B will be covered if the request meets specific clinical criteria.

Drugs that require step therapy

Step therapy programs for the FlexRx formulary vary based on employer group. See which drugs are included in the standard FlexRx step therapy program (PDF).

Please call the number on the back of your member ID card for information on step therapy programs included in your benefit plan.

Drug categories and medications are subject to change without notification.

How to find the step therapy exception authorization request form

The Step Therapy Authorization form is available at ccstpa.com on the "Forms" link within the provider service center.

Prime Therapeutics LLC is an independent company providing pharmacy benefit management services.