Step therapy requirements

Before Priority Health plans will authorize the use of some specified agents, the physician is required to show documented evidence of the therapeutic trial and clinical failure of other drugs (or other drug class). This process is commonly referred to as step therapy.

Determining which drugs have step therapy requirements
Refer to the formulary for the patient's Priority Health plan to look up step therapy requirements by drug name.

Requesting an exception to step therapy requirements
Exceptions may be granted on a case-by-case basis. Ask about step therapy requirements or request an exception by sending us a secure message (click the "Mailbox" selection in the green navigation bar at the top of this page) or calling Customer Service.

How does Priority Health set step therapy requirements?
The Priority Health Pharmacy and Therapeutics Committee considers clinical effectiveness, potential for adverse events, and total overall cost of therapy. This is especially important since many new drugs do not offer significant clinical advantages for a much higher cost.

Documenting therapeutic trial and clinical failure
The Pharmacy and Therapeutics Committee has approved the requirement for a physician to show documented evidence of therapeutic trial and clinical failure of a drug or drug class before Priority Health will authorize the use of specific agents.

Exceptions may be granted on a case-by-case basis taking individual information into consideration.