Step Therapy Applications
| Condition | Step 1 (Generic) | Step 2 (Preferred Brand) | Step 3 (Non-Preferred) |
|---|---|---|---|
| Hypertension | ACE inhibitor generic | ARB preferred brand | ARB non-preferred |
| Depression | SSRI generic | SNRI preferred brand | SNRI non-preferred |
| Diabetes | Metformin generic | GLP-1 preferred brand | GLP-1 non-preferred |
| Rheumatoid arthritis | Methotrexate generic | TNF inhibitor preferred | TNF inhibitor non-preferred |
Clinical Appropriateness
Step therapy must be clinically appropriate. Step therapy that requires patients to try drugs that are contraindicated for their condition, that they have already tried and failed, or that are clinically inappropriate is both ineffective and potentially harmful. Step therapy programs must include exceptions for: (1) prior treatment failure; (2) contraindications; (3) clinical urgency; and (4) physician attestation of medical necessity.
State Step Therapy Laws
Compliance Note
Many states have enacted step therapy laws that limit the use of step therapy for certain conditions or require exceptions for prior treatment failure. Self-funded plans are generally exempt from state step therapy laws under ERISA preemption — but fully insured plans must comply. Review your state's step therapy laws if you have a fully insured plan.