Find out what step therapy is and what you can do if your prescribed treatment requires it.
Sometimes, before your insurance plan will pay for an expensive medicine or therapy, you need to try similar but less expensive treatments first. This process is called step therapy.
Insurance companies have a series of safe and effective treatments to try before you step up to the more expensive one. The number of these steps depends on your insurance plan and the medication. You can ask your doctor or pharmacist to check if step therapy is needed for your medicine.
Since step therapy typically starts with generic drugs with lower copays, the process can help you save money by finding effective treatments at a lower cost.
This process is typically applied to treatments for chronic conditions where multiple medication options are available, such as:
Start with basic anti-inflammatories before complex medicines.
Try generic antidepressants before newer formulations.
Use generic statins before brand-name alternatives.
Begin with metformin before newer diabetes medications.
Start with established heart medications.
After your doctor sends your prescription, you may receive a notice saying that lower-cost treatments must be tried before your new medication is covered by insurance.
You can work with your doctor to start with the approved alternative. To move to the next step, or more expensive therapy, you need to meet at least one of the following reasons:
- You can show that you have already tried a similar generic.
- You have an allergy or intolerance to the similar generic.
- The generic medication did not effectively treat your condition.
- You have an FDA-labeled contraindication to the generic drug.
Your doctor must give medical records explaining your reason to step up to another medication. You might need to try several drugs before finding one that works for you.
First, you'll want to review your formulary. Check your plan's list of approved drugs to understand what medications require step therapy for your condition. Work with your doctor to gather the records needed for an exception or to appeal a decision.
Make sure to keep detailed track of how you respond to each medication, including how well it works and its side effects. Ask your pharmacy and doctor how long approval might take so you can plan.
If your exception is denied, you may have the option to appeal. You should receive a reason why it was denied, giving you the chance to submit additional information.
To appeal a decision, your doctor can provide more details about your condition, health history, and any treatments you've already had.
Keep in mind that the appeals process can vary depending on your state's regulations.
Get reliable answers to your insurance questions, such as how to get prior authorization and submitting a claim.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
Information in other languages: Español 中文 Tiếng Việt 한국어 Français العَرَبِيَّة Hmoob ру́сский Tagalog ગુજરાતી ភាសាខ្មែរ Deutsch हिन्दी ລາວ 日本語
© 2025 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.