Describe prior authorization and step therapy within Part D formularies.

• A. Prior authorization requires plan approval before coverage; step therapy requires trying cheaper alternatives before higher-cost options are approved.
• B. Step therapy requires trying cheaper alternatives before higher-cost options are approved.
• C. Prior authorization is optional; step therapy is not used.
• D. Step therapy means always favoring the most expensive drug first.

Answer: (B)

Step therapy in Part D formularies is a utilization-management approach where a patient must try a lower-cost, evidence-based option before a more expensive drug will be approved for coverage. The idea is to start with the most cost-effective therapy and only move to the pricier option if the cheaper choice proves ineffective or unsuitable. For example, a plan might require trying a generic antidepressant before approving a more expensive brand-name option.

Prior authorization is a separate process in which the insurer must give approval before a specific drug is covered, often used for high-cost or high-risk medications or when clinical documentation is needed. The statement that best describes the mechanism you’d encounter in the formulary is the one that emphasizes trying cheaper options first before approving higher-cost drugs.