How do plans handle step therapy and when can exceptions be granted?

• A. Plans may require trying lower-cost alternatives first; exceptions can be granted if a clinician documents medical necessity or contraindications to alternatives.
• B. Plans require the most expensive drug first.
• C. Exceptions are never allowed.
• D. Step therapy applies only to vaccines.

Answer: (D)

Step therapy is a plan’s method for guiding prescription choices by starting with lower-cost, evidence-based medications before approving more expensive options. An exception can be granted when a clinician documents medical necessity or a contraindication to the cheaper option, allowing coverage of the higher-cost medicine without first trying the cheaper one. This approach helps ensure patients get effective treatment while encouraging cost-effective choices, with an explicit process to review and approve exceptions when warranted. Note that step therapy is a tool mainly used for prescription drugs, not vaccines, which follow different coverage policies.