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Here’s what you need to know when covering ‘step’ therapy

All physicians, and especially those who care for patients with chronic conditions, complain that health insurers too often override their treatment decisions to control costs and ostensibly to improve care.

As of Jan. 1, health plans are allowed to override even more treatment decisions under a new rule from the federal Centers for Medicare and Medicaid Services. The rule allows Medicare Advantage plans use step therapy to restrict coverage when physicians prescribe drugs under Medicare Part B. In a step therapy protocol, a patient must fail to improve on a lower-priced medication before the insurer allows the patient to use a more costly drug, as Paul Sisson explained for The San Diego Union-Tribune. Also known as step protocol or fail first, step therapy is a form of prior authorization, a topic we covered in a tip sheet in August.

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