Step Therapy History Check
Whether a patient's drug history meets a plan's step therapy.
Open the tool → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.
Example
- Required steps, one per line
- conventional DMARD, 2, 90 TNF inhibitor, 1, 84
- Drugs tried, one per line
- methotrexate, conventional DMARD, 2025-01-10, 2025-06-30, inadequate response leflunomide, conventional DMARD, 2025-06-01, 2025-07-15, intolerance adalimumab, TNF inhibitor, 2025-08-01, 2026-03-01, inadequate response
- Plan accepts intolerance or a contraindication in place of a full trial
- Yes
Result: Every required step is met (2 steps).
The tool opens with these values already filled in. Replace them with your own.
What you enter
- Required steps, one per line: step name, number of agents, minimum days
- Drugs tried, one per line: drug, step, start date, stop date or "ongoing", reason (inadequate response, intolerance, contraindication, still taking)
- Plan accepts intolerance or a contraindication in place of a full trial
- Plan type
- Request date (YYYY-MM-DD)
- Last claim for the requested drug (YYYY-MM-DD)
How this is calculated
Citation
42 CFR 422.136(a)(1): a Medicare Advantage plan may apply step therapy to a Part B drug only for new administrations, with a lookback of at least 365 days. Other steps, trial lengths and exceptions are the plan's policy, entered by the reader. Read the source ↗
A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.