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What is Step Therapy?

Step Therapy directs members to clinically safe and cost-effective medications. This program creates the potential for plans to achieve the following benefits:

  • Provides an opportunity for member savings by using clinically preferred and/or more cost-effective medications
  • Reduced pharmacy costs
  • Improved formulary management and positioning

How does Step Therapy work?

When the member is prescribed a medication that is targeted under the Step Therapy Program, the member is directed to a preferred cost-effective medication as an initial step in treatment. The member must try the lower-cost “Step 1” medication before a higher-cost “Step 2” medication will be covered.

Included in the Step Therapy Program are medications used to treat several common medical conditions:

  • ADHD
  • Depression
  • Dermatology
  • Diabetes
  • Hepatitis C
  • High Cholesterol
  • Hypertension
  • Inflammatory Conditions
  • Mental Health
  • Pain (Narcotic and NonNarcotic)
  • Respiratory Conditions
  • Sleep Disorders

Are you participating in the BeRx Step Therapy program? If so, below is a look at what to expect as part of the BeRx member experience:

  1. Member submits prescription to dispensing pharmacy.
  2. The online claims processing system automatically screens prescribed medication against the list of medications identified as part of the Step Therapy Program. If prescribed medication is not subject to step therapy, claim processes successfully.
  3. If prescribed medication is part of Step Therapy Program, the online claims processing system automatically screens member’s pharmacy claims history for the prior use of preferred alternatives. If member’s pharmacy claims history shows use of preferred alternative, claim processes successfully.
  4. If member’s pharmacy claim history does not show the use of preferred alternatives, the claim does not process, and the pharmacist is advised to contact prescribing provider. If the provider changes Rx to the preferred alternative, claim processes successfully.
  5. If the provider chooses to submit a prior authorization (PA) request for coverage, PA process is initiated.

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Wellfleet is the marketing name used to refer to the insurance and administrative operations of Wellfleet Insurance Company, Wellfleet New York Insurance Company, and Wellfleet Group, LLC. All insurance products are administered or managed by Wellfleet Group, LLC. Product availability is based upon business and/or regulatory approval and may differ among companies.