Summary Plan Description
Step Therapy Program
A step therapy program is designed for patients with certain conditions that require taking medications regularly. It is the practice of beginning medication therapy with the most cost-effective medication and only moving to other more costly therapy(s) if the initial medication does not provide adequate therapeutic benefit. The step therapy program applies to purchases from participating and nonparticipating pharmacies and the Express Scripts Medicare Prescription Plan.
In step therapy, medications are grouped in two categories:
Step 1: First Line Medications – medications proven safe, effective, and affordable.
Step 2: Second Line Medications – mostly higher costing brand-name medications.
In step therapy, the patient will be required to try a First Line Medication (Step 1) before approval of a Second Line Medication (Step 2). If the Step 1 therapy does not provide the appropriate therapeutic benefit, the patient's physician can write a prescription for a Step 2 medication.
If you currently take a Second Line Medication, your physician should: (1) write a prescription for a First Line Medication; or (2) submit a Letter of Medical Necessity to Express Scripts for the continued use of the Second Line Medication. The Letter of Medical Necessity should state the Second Line Medication is medically necessary for you to be on and the exact dosage and quantity. A Letter of Medical Necessity must be submitted annually. You or your physician can begin the Letter of Medical Necessity process by contacting Express Scripts Member Services at (800) 669-3897.
Always talk to your physician before discontinuing or changing any medication. If you have medical questions, please contact your health care provider. We encourage you to work with your physician to determine which medication options are best for you.
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