Step Therapy Process

Step therapy is intended to use the most cost-effective and safest drug available for a specific medical condition.

For you to receive step-therapy drugs, your provider must prescribe certain drugs before trying another. Step therapy programs require your provider to prescribe Step One drugs before Step Two drugs.

We realize the "first step" drug may not always be the best drug for you. If you used a Step One drug without getting the results you and your provider would like, your provider can request a step therapy review which may lead to an override.

What happens at the Pharmacy?

  • The pharmacist enters your prescription information into the claims system.
  • If a drug is a Step Two drug, the pharmacist will receive a message about the step therapy requirements.
  • The pharmacy will contact your provider.

Your provider can:

  • Prescribe a Step One drug or
  • Fax Avera Health Plans at 1-800-269-8561 to request a step therapy override. (This may take up to 72 hours to complete).

If the override is approved: The pharmacy will fill your prescription for the appropriate co-pay or co-insurance.

If the override is denied: Your provider will need to prescribe a Step One drug.

If you and your provider decide not to go through the override process, your provider can prescribe a Step Two drug and you will pay the entire cost of the prescription.