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Step Therapy

For some medications, you may be required to first try clinically appropriate generic and preferred brand alternatives when available. This process is known as “step therapy,” and your pharmacy will notify you if your prescribed medication requires it. The pharmacist will receive a message from CVS/caremark letting him or her know which prescription alternatives to offer you.

Here’s how it works:

  1. Try the required number of generic options first.
  2. Try a preferred brand(s).
  3. If treatment with a generic and preferred brand medication fails, talk to your doctor about submitting a prior authorization request documenting the treatment failure. Or if the brand is necessary because of a clinical concern (such as an allergy), ask your doctor to submit the clinical concern with the prior authorization request.
  4. If prior authorization is approved, the plan will cover the brand medication. If your request for a brand is declined, you have the option to purchase the brand at your own expense.

If CVS/caremark denies your request for a step therapy exception, you can purchase the drug at your own expense. You or your doctor may also file an appeal for a denied medication. For additional information, call CVS/caremark at 1-866-889-0471. The costs for non-covered medications do not apply to your deductible or coinsurance. PCA funds may not be used for reimbursement.

 

 

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