Step Therapy

Step therapy is a pharmacy management program used by TRICARE that requires beneficiaries to try one or more lower-cost medications before the plan will cover a more expensive drug. Also known as "fail first," step therapy helps ensure cost-effective prescribing while maintaining quality care.

How step therapy works: • Your provider prescribes a medication that requires step therapy • TRICARE requires you to first try a lower-cost alternative (the "first step" drug) • If the first-step drug is ineffective or causes side effects, your provider documents the failure • TRICARE then approves coverage for the originally prescribed medication

Step therapy in TRICARE pharmacy: • Applies primarily to brand-name and specialty drugs • Generic alternatives are often the required first step • Documented medical exceptions may bypass step therapy • Your provider can request an override with clinical justification

Exceptions to step therapy: • Emergency medications • Documented adverse reactions to first-step drugs • Clinical contraindications documented by your provider • Previously failed the required first-step medication

Step therapy helps control pharmacy costs while ensuring beneficiaries receive effective treatment. If you believe step therapy is not appropriate for your situation, discuss alternatives with your provider.