Step Therapy
Some drugs require step therapy. This means you must try one or more other drugs before a step therapy drug is covered.
The other drugs are called prerequisite drugs. They are equally effective, have FDA approval, may cost less and work just as well. They treat the same condition as the step therapy drug.
If you do not try the other drugs first, you may need to pay full cost for the step therapy drug.
- You take a generic drug to lower your cholesterol, but it’s not working.
- Your doctor prescribes another medication, but it’s still not working.
- Your doctor prescribes a different medication that works well. But it’s more expensive. You find out that it requires step therapy.
Before the plan will cover the more expensive drug, Aetna will check to see if you’ve tried the lower-priced drug in the past six months. In this case, you have tried the lower-priced drug, so the step therapy drug will be granted an exception and covered under the plan.
You will need to follow the process for step therapy when it’s required. Otherwise, the drug may cost you more, or may not be covered at all.
Start by reviewing our plan’s formulary. If you see a “ST” after the name of your prescription, you may need to try step therapy. You or your pharmacist should tell your doctor. There may be another drug they can prescribe that doesn’t require step therapy.
The drug my doctor prescribed requires step therapy. If the drug is necessary for treating my condition, how can I get an exception?
To request an exception:
- You or your doctor can call the Aetna Pharmacy Precertification Unit at 1-800-414-2386.
- You can log in to your secure member website and submit a request through the Contact Us feature.
- You or your doctor can fill out a request form and send it to Aetna:
- By fax. The fax number is on the form.
- Through our secure provider website, Navinet - only your doctor can use this option.
- By mail. The mailing address is:
Aetna Pharmacy Management
1300 East Campbell Road
Richardson, TX 75081
