By Spencer Sherman, Pharm.D., Clinical Accounts Pharmacist, Enlyte
When reviewing a medication request, it’s not always clear why one drug is approved first and another is not. That is where step therapy comes in. In workers’ compensation, step therapy gives you a structured, evidence-based framework for evaluating medication requests, starting with well-supported, lower-risk treatments before moving to other options when medically necessary.
Step therapy follows a logical progression. Injured employees usually begin with first-line medications supported by strong clinical evidence. If those medications don’t work, are not well tolerated or are not appropriate for the employee’s condition, treatment can move to second- or third-line therapies. This approach supports care that is medically appropriate, safe and cost-conscious.
Why Step Therapy Matters When Managing Claims
Step therapy is not meant to restrict care. It is meant to guide it. It can help adjusters:
- Support appropriate prescribing
- Reduce use of higher-risk medications when safer options are available
- Encourage recovery and return-to-work
- Help control pharmacy costs
For adjusters, that means more confidence that a prescribed medication follows an established treatment path and any escalation is supported by a clinical reason.
Clinical Foundations Behind Step Therapy
Step therapy protocols are based on widely accepted clinical guidelines, including the Official Disability Guidelines and the American College of Occupational and Environmental Medicine guidelines. These guidelines help create a consistent framework for medication decisions across claims while still allowing room for individual clinical needs.
How Step Therapy Works in Practice
Pain management is a common example in workers’ compensation. Treatment often starts with non-opioid medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen or meloxicam. If those medications are not enough, treatment may move to more targeted NSAIDs such as celecoxib or to lower-potency opioids such as tramadol. Higher-risk medications are typically considered only when earlier options are ineffective or inappropriate.
The same approach often applies to musculoskeletal injuries such as strains. A provider may start with a well-established medication such as cyclobenzaprine before moving to newer or higher-cost alternatives.
When Exceptions Apply
Step therapy includes safeguards to ensure medically appropriate care is not delayed, and providers can request an exception when:
- The injured employee has already tried and not responded to first-line therapy
- The medication is not appropriate because of the employee’s condition or other medications
- There is a risk of harmful drug interactions
- The clinical situation calls for immediate escalation
These exceptions help ensure that step therapy supports individualized care rather than getting in the way of it.
What This Means When Reviewing Medication Requests
When reviewing a medication request, step therapy can help you quickly assess whether the treatment follows an appropriate clinical path.
Start by identifying whether the requested medication aligns with first-line treatment guidelines. If it’s a higher-step medication, look for documentation that explains why earlier options were not effective, not tolerated or not appropriate for the injured employee’s condition.
If that clinical rationale is clearly documented, the escalation may be justified. If not, it may indicate an opportunity for further review or clarification.
Using this approach can help you make more informed decisions and ensure treatment aligns with clinical guidelines and claim goals.
About the Author
Spencer is a clinical pharmacist for Enlyte Pharmacy Solutions. In his role, he serves in a client facing capacity as part of the Pharmacy Benefit Management (PBM) team and is responsible for supporting and partnering with insurers, third party administrators and direct employers in developing and operationalizing strategic pharmacy initiatives for their clinical programs.
Spencer is also a regular contributor to the Ask the Pharmacist Series where this article originally appeared.
www.enlyte.com/ask-the-pharmacist
