Posting this under the heading it deserves: Step therapy requirements and how to satisfy them Everything below is what sits behind that.
I would like to know what people here actually do about step therapy requirements, as distinct from what is usually recommended. Those have diverged in every other subject I have looked at closely.
Mine is below, with the reasoning, including the parts I am not confident about.
The question underneath step therapy requirements is usually "how would I tell?" rather than "what is true?", and that one has a method attached to it.
Write down what you would expect to see under each hypothesis before you collect anything. If they predict the same observation, collecting it will not help.
Where I have landed on step therapy requirements, having got it wrong once in public: the direction is clear, the magnitude is not, and anyone quoting a precise magnitude has borrowed it from somewhere that did not measure it.
Nothing to add, except that this is the answer I would give if asked.
Out-of-pocket costs: if insurance is not covering it, asking about patient assistance programmes run by manufacturers can reduce costs. Eligibility requirements exist but many people qualify.
Adding this to the thread rather than to the wiki, because I am not confident enough for the wiki.
The confident answers on step therapy requirements and the well-sourced answers are not the same answers, which is the most useful thing I have learned reading this category.
Two things can be true about step therapy requirements at once: the mechanism is plausible and the evidence for the size of the effect is thin. Most of the argument here is people defending the first against attacks on the second.
Answering the question post #6 raises rather than the one it answers.
Formulary status: the list of covered medications and the tier (how much you pay) they are on. Checking the current formulary before going to a clinic appointment saves surprise at the pharmacy.
I read post #6 twice before replying, because I had assumed the opposite.
Step therapy requirements is well covered in the tag pages, and the older discussions are better than the recent ones because they were argued out properly. Worth twenty minutes before adding to this one.
Prior authorisation: pre-approval requirements and how to satisfy them. Most denials cite specific criteria. Understanding the criterion is the first step in satisfying it.
A weak preference rather than a position.
Picking up post #9: that is the part I would want checked first.
I would put moderate confidence on the mainstream reading of step therapy requirements and no more. That is not scepticism for its own sake; it is where the sourcing actually stops.
Answering the step therapy requirements question as asked, then the question I think is meant. As asked: yes, with the qualification below. As meant: it depends on how the first measurement was taken.
Nothing here is legal or medical advice, and appeal processes differ enough by jurisdiction and payer that specifics do not transfer.
Happy to be the one who is wrong here if it settles the question.
Post #13 describes the usual case. This is about the unusual one.
Worth separating step therapy requirements as a question about the compound from step therapy requirements as a question about the documentation. They get answered by different people and only one of them is answerable here.
Adding the measurement that post #13 says would settle it.
Small correction to my own earlier position on step therapy requirements. I had the units the wrong way round, which changes the conclusion by an order of magnitude and therefore changes it entirely.
Keep every document with dates in one place. An appeal months later is assembled from whatever you kept.
Not the whole picture, but the part of it I can speak to.
On step therapy requirements: the maintained page in the documentation commons covers the general case with citations and a review date, which is more reliable than any reply here including this one.
Post #17 and I disagree about the size of the effect, not about the direction.
Nothing here is legal or medical advice, and appeal processes differ enough by jurisdiction and payer that specifics do not transfer.
The reason step therapy requirements keeps being re-asked is that the answer is conditional and people quote it without the condition. It is not that the answer is unknown.
Narrowing post #18, because the general version has more than one answer.
I have been on both sides of the step therapy requirements argument in this category within eighteen months, which should tell you how strong the evidence for either side is.
Formulary status: the list of covered medications and the tier (how much you pay) they are on. Checking the current formulary before going to a clinic appointment saves surprise at the pharmacy.
Reimbursement changes: a compound covered one year might not be the next. A formulary decision in January can change by April. Checking again before refilling saves frustration.
What I want from this step therapy requirements thread is the list of things that would need to be true for the claim to hold. If we can write that list, we can check it.
On step therapy requirements, I would rather understate and be corrected upward than overstate and be quoted. That is a house style here and it is a good one.
| Topic | Participants | Replies | Views | Activity |
|---|---|---|---|---|
|
About the Insurance & coverage category
Prior authorisation, appeals, denial letters, and documentation that helps. This post is a community wiki: any member at trust level 3 or above can edit it, and every edit is recorded with its author and a…
|
+2 | 6 | 3.2k | 3mo |
|
Revisiting: Reading a denial letter as a specification for your appeal
Posting this under the heading it deserves: Revisiting: Reading a denial letter as a specification for your appeal Everything below is what sits behind that. Asking about Reading a denial letter on behalf of…
|
+125 | 138 | 9.4k | 10mo |
|
Prior authorisation: what the criteria usually require
On the subject in the title: Prior authorisation: what the criteria usually require Working notes rather than a conclusion. I would like to know what people here actually do about prior authorisation, as…
|
+9 | 13 | 3.2k | 17mo |
|
Peer-to-peer review: what actually happens on the call — one year on
Peer-to-peer review: what actually happens on the call — one year on — setting out what I have, and where I think it stops being reliable. The question about Peer-to-peer review that I actually want answered…
|
+2 | 6 | 41k | 5mo |
|
Reading a denial letter as a specification for your appeal
Reading a denial letter as a specification for your appeal Writing it up because I had to work it out twice and would rather nobody else did. Reading back through what has been written here about reading a…
|
3 | 30k | 12mo |
| Topic | Participants | Replies | Views | Activity |
|---|---|---|---|---|
|
About the Pricing category
List prices, negotiated prices, and cost per milligram compared honestly across formats. This post is a community wiki: any member at trust level 3 or above can edit it, and every edit is recorded with its…
|
+1 | 5 | 18k | 15mo |
|
Telehealth prescribing models in the US
Telehealth prescribing models in the US Writing it up because I had to work it out twice and would rather nobody else did. Trying to work out what would count as evidence on telehealth prescribing models,…
|
+95 | 102 | 6.1k | 14mo |
|
Canadian access and provincial variation — one year on
Canadian access and provincial variation — one year on Writing it up because I had to work it out twice and would rather nobody else did. A follow-up question about Canadian access and provincial variation…
|
+43 | 47 | 964 | 12mo |
|
An appeal that succeeded, with the letter structure
On the subject in the title: An appeal that succeeded, with the letter structure Working notes rather than a conclusion. Appeal, and specifically the version of it that the documentation does not cover. The…
|
+12 | 16 | 15k | 1d |
|
What to bring: records that a clinician can actually use — a second dataset
What to bring: records that a clinician can actually use — a second dataset I have a specific reason for asking rather than idle curiosity, and the context is below. A question about how to describe something…
|
+80 | 86 | 5.6k | 3h |