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Provider Manual

Step Therapy

Last Updated on December 31, 2019

Step therapy is a pharmaceutical utilization management tool that requires using one or more drugs in a step-wise approach. Step therapy programs typically promote the use of generics or other cost-effective alternatives as the first choice drug before progressing to more costly alternatives. Step therapy is in place of a traditional prior authorization process when a trial with a preferred first-line drug is the only prerequisite for coverage.

In cases when the member requires the step therapy drug as a first-line option, supporting documentation is requested from the provider. Exceptions will be considered if first-line drugs are inappropriate, for example, due to a valid medical contraindication. To request an exception, see below.

How does Security Health Plan decide which prescription and medical drugs require utilization management?

Security Health Plan’s Pharmacy and Therapeutics (P&T) Committee determines criteria to promote safe and effective use of drugs.

Policies are determined based on established clinical practice guidelines, clinical evidence, cost-effectiveness and the availability of alternatives to ensure safe, effective and proper use of drugs and health care dollars.  Clinical evidence may include peer-reviewed medical literature, accepted national treatment guidelines and opinions of clinical experts in various medical specialties.

How does a provider request an exception for a Step Therapy Medication?

The process for requesting an exception of a Step Therapy Medication may commence by communication between the prescriber and SHP pharmacy staff.

  • The prescriber's request must provide the following:
    • member name;
    • prescriber name, address, and telephone number;
    • drug, strength, dosage form, and directions;
    • Completed Step Therapy Override Determination Form

The Step Therapy Override Determination form can be found by logging into your Security Health Plan  Provider portal.

  • Information provided must be sufficient to assess whether the request meets criteria for approval.
  • If the prescriber provides an oral supporting statement, the Health Plan may require the prescriber to subsequently provide a written supporting statement.
  • The prescriber may also be required to provide additional supporting medical documentation as part of the written follow-up.
  • The request and supporting documentation may be delivered in written form or electronically via one of the following methods:
    • Written requests should be sent to:
      • Security Health Plan
      • ATTN: Pharmacy Services
      • PO Box 8000
      • Marshfield, WI 54449-8000
    • Email: shprx@securityhealth.org
    • Call: Security Health Plan Pharmacy Services: 1-877-873-5611, Monday-Friday 8am-5pm
      • if you are hearing- or speech-impaired call TYY 711
    • Fax: 715-221-9989
  • For a “Standard” request, decision shall be granted or denied within 3 business days of receipt of the completed Step Therapy Override Determination form.
  • For an Urgent or “fast” request, an approval or denial will be granted by the end of the next business day after receipt of the complete Step Therapy Override Determination form