What is Step Therapy, as it pertains to Medicare Part D ?

Question

is it the same as utilization management?

Answer 1

working for a medicare HMO, I can tell you what Step Therapy is..
Step Therapy is where you try something before obtaining something else. For example : If someone is wanting Nexium - a lot of insurance companies will not pay for this drug because it's expensive, so they want you to try prevacid, or prilosec before obtaining nexium. if your doctor suggests that you have tried other things and nexium is the only thing that works for you, he could sumbit an authorization to the insurance company with a copy of your two last office visits and see if something can be done on your behalf but more than likely you'll have to try something else first. hope that helps!