Insurance companies often want patients to try less expensive prescription drugs first before they try newer, more expensive ones to treat an illness. This is called “step therapy.”
If you need a prescription drug that requires step therapy, you should ask your doctor if the lower cost drug will be safe and effective.
If your doctor says “yes”…
- Your doctor might write you a new prescription for the lower cost drug.
If your doctor says “no” (it is not safe or effective for you)…
- You should file an appeal with your insurance company.
- Your doctor should tell the insurance company why it's not safe or effective.
For example: If you have an allergy or have tried the drug before and it didn’t work for you, your doctor will need to write down:
- the reasons why you cannot take the lower cost medication,
- the dates when you tried the medication, and
- why it didn't work or wasn't safe.
Then the doctor will send that information to your insurance company.
In Vermont, there is also a “generic substitution policy.” This law says that if a generic form of a medication is available, it should be given out before the more expensive brand name form. Your doctor can change this policy in certain situations if you need a brand name drug or if generic drugs are not-preferred or unavailable.