We all know that health insurance can be downright complicated. It’s mysterious and elusive to those who aren’t in the medical field, and uncovered costs can be extremely expensive. Moreover, figuring out what’s covered and what’s not is often disorienting—like deciphering a language you don’t read, speak, or write.
Insert step therapy. It’s a policy developed by insurance companies to cut down on prescription drug costs (though it does also help make medications accessible in all communities.) Essentially, health insurers use it to restrict the use of more expensive drugs unless it’s been shown that the lower-cost versions are less effective or don’t work. Ever been in the doctor’s office and heard the term “prior authorization”? Step therapy is much like this. It means that your health insurance company must approve a drug before your pharmacy can fill it.
This strategy has gotten a lot of criticism. Many feel that step therapy impedes a patient’s ability to get the medications they need for their health and the most effective treatment. And there may be some truth to that. But you can also use step therapy to your advantage by getting coverage for “off-label” generic prescriptions. The providers at Found can discuss the details and answer your questions. But here are some basics.
1Most health care plans require you to use step therapy to get the most cost-effective drugs before prescribing a more expensive one. For instance, you have to “fail first,” meaning you must try a cheaper medication first. Then when it doesn’t work, your insurance company will cover the next level of drugs which are pricier and perhaps more effective medications. With step therapy, you’ll try a variety of drugs until you find the one that is right for you.
Say you suffer from acne. Your dermatologist has you try an OTC remedy; when that doesn't work, they give you a prescribed medication to treat it. When that doesn’t work, they prescribe another medication—and another and another—until you finally get results.
Those are the steps (or tiers) we’ve been talking about. Here’s how they work:
Tier 1: These are generic medications, also referred to as first-in-line. They’re the most cost-friendly and are typically covered by insurance plans.
Tier 2: These are what are called “preferred” brand-name medications. That’s insurance-speak for drugs that cost more than generics but aren’t as expensive as other options. So they’re the next go-to.
Tier 3: Know how we talked about “preferred” brand-name medications? Well, you might have guessed that this level is “non-preferred” brand medications. Your insurance company wants to steer clear of these as much as possible. Suppose your doctor feels your treatment should start with a step 3-level medication. In that case, they’ll need to submit a prior authorization request to get approval for the drug to be covered by your insurance.
Generic drugs have the same active ingredients and dosage as the brand-name versions. According to the U.S. Food and Drug Administration, “You can take a generic medicine as an equal substitute for its brand-name counterpart.” Generic drugs go through the same rigorous testing as brand-name medications but are often pennies on the dollar. The only difference is that they won’t have the brand-name packaging and maybe a different shape or color. So you (and your insurance company) can save tons of money on effective and cost-friendly medications.
4Generic tier (step-one drugs) are usually prescribed first, so your insurance covers some or all of the cost of your Rx, leaving a small copayment. With this in mind, Found often prescribes generic medications for sustainable weight loss, which will be covered by your insurance. But step therapy can help you get the right treatment, even if you have to try multiple medications before finding one that works. So when prescribing a new drug, your Found health care provider considers all of this. This is important, especially for the off-label drugs used to treat overweight and obesity, since some insurance plans require it to be a generic drug.
Found is among the largest medically-supported weight care clinics in the country, serving more than 200,000 members to date. To start your journey with Found, take our quiz.