What is step therapy in drug coverage decisions?

• A. Requiring trying lower-cost, guideline-concordant therapies before more expensive options are approved.
• B. Paying providers for each service regardless of outcome.
• C. Coordinating primary care across multiple settings.
• D. Classifying hospital cases by resource use.

Answer: (A)

Step therapy is a drug coverage approach where a plan requires you to start with a lower-cost, guideline-supported therapy before approving a more expensive option. This “fail-first” model aims to use treatments with proven effectiveness and safety while controlling overall costs. If the initial therapy isn’t effective or isn’t tolerable, the plan may authorize the higher-cost drug after appropriate documentation. Exemptions can apply for safety concerns, prior intolerance, or specific clinical situations.

This description fits best because it directly captures the process of starting with cheaper, guideline-consistent options and moving to pricier alternatives only if needed. The other options describe different concepts: paying providers per service is fee-for-service payment, coordinating primary care across settings is care coordination, and classifying hospital cases by resource use is a hospital payment categorization system.