Step Therapy
A payer requirement that less expensive drug or service options be tried before more expensive alternatives are covered.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- Payer
- Primary sources
- 1
- Workspace handoff
- denial workbench →
Where this comes up
Front-office and billing both hit this term — eligibility before the visit, prior auth before the procedure, contract terms during fee-schedule negotiation, and credentialing whenever a new provider joins or a payer roster lapses. Misses here become denials downstream.
Full definition
What it is in practice
Step therapy is permitted in Medicare Part D and increasingly in Part B (under MA plans, per CMS guidance). Exceptions and appeals are statutory.
How it shows up in your practice
Document failed therapies before stepping up. Anticipate step-therapy denials on high-cost drugs and prepare appeal templates.
Sources
- CMS — Medicare Part Dhttps://www.cms.gov/medicare/coverage/prescription-drug-coverage
Defend step-therapy denials in the Denial Workbench
Open denial workbench →Related terms
- PayerPrior AuthorizationPayer requirement that the practice obtain approval before delivering certain services, procedures, or drugs.
- Denials & AppealsAppeal LetterThe written request to a payer to reconsider a denied or partially-paid claim.
- Denials & AppealsDenial ManagementThe end-to-end workflow of identifying, categorizing, appealing, and preventing claim denials.
D3rx is a healthcare-billing and compliance research aid maintained by D3rx Inc. Articles are drafted by an LLM (Anthropic Claude) against primary HHS, OCR, CMS, eCFR, NIST, and state-regulator publications, and reviewed for restraint and source fidelity by the D3rx team.
Reviewer status: a named credentialed reviewer (CHC, CHPC, or healthcare attorney) is being engaged. Until that engagement is finalized, this page does not claim credentialed review.
Related across the archive
- GlossaryPrior AuthorizationPayer requirement that the practice obtain approval before delivering certain services, procedures, or drugs.
- GlossaryAppeal LetterThe written request to a payer to reconsider a denied or partially-paid claim.
- GlossaryDenial ManagementThe end-to-end workflow of identifying, categorizing, appealing, and preventing claim denials.
- GlossaryFormularyA health plan's list of covered drugs, typically organized by tier with associated cost-sharing.
- GlossaryMedicare Part DMedicare prescription drug coverage delivered through stand-alone PDPs or MA-PD plans.
- ComplianceOIG LEIE Monthly Exclusion Screening: Process + Audit-Ready LogsMonthly OIG LEIE and SAM.gov exclusion screening for every workforce member and vendor: the workflow, the log fields auditors require, and the escalation path.
- CompliancePECOS Provider Enrollment Verification (2026) — Quarterly ChecklistQuarterly PECOS provider enrollment verification workflow: who to check, the exact lookup steps, the audit log columns, and the revalidation escalation path.
- Glossary270/271 Eligibility Inquiry/ResponseThe HIPAA standard EDI transactions used to verify patient insurance eligibility (270 query, 271 response).
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.