A non-government resource for the Medicare community
Powered by Q1Group LLC
A non-government Medicare community resource
  • Menu
  • Home
  • Contact
  • MAPD
  • PDP
  • 2024
  • 2023
  • FAQs
  • Articles
  • Search
  • Contact
  • 2024
  • 2023
  • FAQs
  • Articles
  • Latest Medicare News
  • Search

What is Step Therapy (ST) in Medicare Part D?

Category: Q&A of the Day
Updated: Oct, 23 2023

Step Therapy is a utilization management restriction that your Medicare Part D prescription drug plan can add to a formulary medication.

According to the Centers for Medicare and Medicaid (CMS) "Step Therapy" is defined as:
When your Medicare Part D plan requires you to first try one (usually less-expensive) drug before the drug plan will pay for coverage of another (usually more-expensive) drug for that same medical condition.  For example, if Drug AA and Drug BB both treat your medical condition, your Medicare plan may require your doctor to prescribe Drug AA first.  If Drug AA does not effectively treat your condition or work for you, then the plan will then cover Drug BB.
(source: Medicare.gov)

On our Medicare prescription drug finder (Q1Rx.com), we use "S" to designate that the Medicare Part D plan requires Step Therapy for a particular medication.  Here is an example screen for "FETZIMA 20-40 MG TITRATION PAK (28 EA) (NDC: 00456220228)" showing that the medication has both a usage management restriction for "S" step therapy and "Q 56 / 365" or quantity limit of 56 per year.

Q1Medicare Q1Rx Drug Finder

For another example, you can click here for an example of our 2024 Drug Finder search (FANAPT 1 MG TABLET (60.000 EA) (NDC: 43068010102)) showing a medication and the plans that have various utilization management restrictions (Quantity Limits, Step Therapy, Prior Authorization - such as: S Q:60/30Days -- meaning: this medication requires Step Therapy and has a Quantity Limit of 60 per 30 days).

As reference, here is our Q1Rx.com Drug Finder "key" to Medicare Part D utilization management restrictions.
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt)
  • None - This drug does not fall under any drug utilization management controls.
  • P - Prior Authorization -This drug is subject to prior authorization.
  • S - Step Therapy -This drug is subject to step therapy.
  • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.
The downside of a Step Therapy restriction: The time necessary when trying alternative drugs.
Since a formulary drug subject to Step Therapy requires you to try a less-expensive medication (or a medication on a lower-costing formulary tier) before your Medicare Part D drug plan will pay for the higher-costing formulary drug that your doctor may have originally prescribed - the downside of Step Therapy is that the trial process can take several months before that you and your doctor find that a particular medication does not work as well as another formulary medication that is subject to the Step Therapy restriction.

What to do when you have a Step Therapy restriction.
The good news is that you can avoid Step Therapy by either:

(1) choosing a Medicare Part D plan that does not have a Step Therapy restriction for your medication or

(2) you can ask your Medicare Part D plan for a Formulary Exception so that you are exempt from the Step Therapy restriction.

You can read more about the Formulary Exception process here:

Medicare Supplements
fill the gaps in your
Original Medicare
1. Enter Your ZIP Code:
» Medicare Supplement FAQs

Browse FAQ Categories

Tips & Disclaimers
  • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.