Prescription Drugs
Step Therapy
Quick answer
Step therapy requires you to try a lower-cost drug first before the plan covers a more expensive alternative for the same condition.
Plain-English definition
You can request an exception if the required step drug isn't appropriate for you.
Why it matters
Step therapy can delay access to your preferred medication.
A simple example
Your plan requires you to try metformin before covering a newer diabetes drug.
Common mistakes & misconceptions
Related terms
Prior Authorization
Prior authorization is a plan requirement that your doctor get approval before a specific drug or service is covered. It's used to confirm medical necessity and steer to lower-cost alternatives.
Coverage Determination
A coverage determination is the plan's formal decision about whether a drug is covered, how much you'll pay, and any requirements like prior authorization.
Tier Exception
A tier exception is a formal request for your plan to charge the lower-tier copay for a drug currently placed on a higher tier.
Frequently asked questions
How do I bypass step therapy?+
Request an exception with your doctor's clinical support.
Sources & references
📚 Where this information comes from
- Medicare.gov — official U.S. government site for people with Medicare ↗Primary source for benefits, enrollment periods, and plan comparison.
- CMS.gov — Centers for Medicare & Medicaid Services ↗Federal rulemaking, program updates, and official guidance.
- Social Security Administration — Medicare enrollment & premiums ↗Enrollment, premium withholding, and IRMAA determinations.
When you're ready, compare plans on your own terms
See Medicare Advantage plans from the insurance companies we represent, or walk the course with a licensed agent whenever you'd like a second set of eyes.
We help compare Medicare Advantage plans from the insurance companies we represent, and we don't offer every plan available in your area.
Medicare Caddies is an independent insurance agency. We are not affiliated with, endorsed by, or connected to the U.S. government, the federal Medicare program, or the Centers for Medicare & Medicaid Services (CMS). We help compare Medicare Advantage plans from the insurance companies we represent, and we don't offer every plan available in your area.