Medicare Advantage

Part D Step Therapy Criteria (2014)

What is step therapy?

Step therapy is a type of prior authorization. With step therapy, in most cases, you must first try certain less expensive drugs that have been proven effective for most people with your medical condition before you can move up a “step” to a more expensive drug. For instance, your plan may require you to first try a generic prescription drug (if available), then a less expensive brand-name prescription drug on the formulary, before it will cover a similar, more expensive brand-name prescription drug. However, if you’ve already tried the similar, less expensive drugs and they didn’t work, or if your prescriber believes your medical condition makes it medically necessary for you to be on the more expensive step-therapy prescription drug, he or she can contact us to ask for an exception. If your prescriber’s request is approved, the plan will cover the step-therapy prescription drug.

An example of step therapy

Step 1: Dr. Jones wants to prescribe a new sleeping pill to treat Mr. Brown’s occasional insomnia. There’s more than one type of sleeping pill available. Some of the drugs Dr. Jones considers prescribing are brand-name only prescription drugs. The plan rules require Mr. Brown to try the generic prescription drug zolpidem first. For most people, zolpidem works as well as brand-name prescription drugs.

Step 2: If Mr. Brown takes zolpidem but has side effects, Dr. Jones can use that information to ask the plan to approve a brand-name drug. If approved, Mr. Brown’s plan will cover the brand-name drug for Mr. Brown.

Coverage of drugs is first determined by your pharmacy or medical benefit. Please refer to your Evidence of Coverage for information about your benefits.

Drug name Step therapy criteria Drug that must be tried first
Maxalt and Maxalt-MLT, naratriptan, rizaptriptan, and Zomig and Zomig ZMT Requiring prior therapy with generic sumatriptan sumatriptan
Vibryd, Pristiq, Marplan Requiring prior therapy with any two of the following drugs: fluoxetine, paroxetine, citalopram, escitalopram, sertraline, venlafaxine, or bupropion fluoxetine, paroxetine, citalopram, escitalopram, sertraline, venlafaxine, or bupropion
Benicar and Benicar HCT Requiring prior therapy with generic losartan losartan
Uloric Requiring prior therapy with generic allopurinol allopurinol
Fanapt, Fazaclo, Latuda, Risperdal Consta, Saphris, Seroquel XR Requiring prior therapy with any two of the following drugs: clozapine, olanzapine, risperidone, quetiapine, ziprasidone clozapine, olanzapine, risperidone, quetiapine, ziprasidone
Celebrex Requiring prior therapy with generic meloxicam meloxicam
Renagel and Renvela Requiring prior therapy with generic calcium acetate calcium acetate
Zolinza Requiring prior therapy with generic fluconazole, ketoconazole fluconazole, ketaconazole

Y0089_MP3536FH Approved 11/06/2013
Last updated: 10/01/2013