Citi Benefits Handbook
Step Therapy
A Step Therapy program is a "step" approach to providing prescription drug coverage .Step Therapy is designed to encourage the use of cost-effective prescription drugs when appropriate .To determine if your prescription requires Step Therapy, or is subject to limitations, call Express Scripts at 1 (800) 227-8338.If you have a discontinuance or lapse in therapy (typically more than 130 days) while using the brand-name medication and need to restart therapy, you will be subject to another review under the Step Therapy program to determine if the cost of the brand-name medication will be covered under the Program .There is no minimum age requirement for Step Therapy.
Here's how Step Therapy works:
1. A member presents a prescription for a drug requiring step therapy at a retail pharmacy or via Home Delivery.
2. The pharmacist enters the prescription information into the Express Scripts information ("ESI") system.
3. The claim is submitted for processing - the ESI system automatically looks back at the member's claim history to see if the member had a prescription filled in that time period for the alternative drug (typically 130 days).
4. If a claim for an alternative drug is found, the claim will automatically process.
5. If there is no history of a prescription filled for an alternative drug, the prescription claim is rejected.
6. The pharmacist can either contact the member's physician to see if an alternative drug is acceptable or advise the member to contact his/her physician.
7. The physician can provide a prescription for an alternative drug. If the physician strongly feels that the original drug prescribed will best treat the member's condition, then he/she can submit a prior authorization request. If the request meets the clinical criteria, the originally prescribed drug will be covered.
8. A notification will be sent to both the member and physician on whether the request has been approved or denied.
Call Express Scripts at 1 (800) 227-8338 or www.express-scripts.com to obtain information on if your medication requires step therapy and/or the applicable copay for the generic, preferred brand or non-preferred category of drug.