The February 28, 2017 issue of the Journal of the American Medical Association (JAMA) published an article by Dr. Michael Fischer and Dr. Jerry Avorn entitled, “Step Therapy—Clinical Algorithms, Legislation and Optimal Prescribing,” that explains the benefits of step therapy, an approach intended to control the costs and risks posed by prescription drugs.
Step therapy is a relatively new program offered by insurers and pharmacy benefits managers (PBMs) that requires patients to try lower cost or generic medications before they can ‘step up’ to a more expensive medication.
For example, a patient with rheumatoid arthritis may be ‘required’ to try the generic medication methotrexate first. If methotrexate does not adequately manage their condition, then their doctor could step up to a specialty pharmacy medication such as Humira or Enbrel.
The primary reason for step therapy is cost. Methotrexate costs $41 per month. Conversely, Humira costs $4,688 per month–$56,256 per year and Enbrel costs $2,345 per month–$28,140 per year. These costs add up, since patients take these medications for years on end.
Additionally, step therapy is typically in line with guidelines created by physicians themselves. For example, the American College of Rheumatology recommends methotrexate as the first-line treatment for rheumatoid arthritis and a recent article admits that it is underutilized by rheumatologists.
The doctors who wrote the JAMA article describe the benefits of evidence-based step-therapy. They cite that a $4 per month first-line medication for diabetes called metformin is only prescribed initially for 66 percent of newly diagnosed diabetics. It should be almost 100 percent.
As a physician who treated many people with diabetes, I saw this phenomenon first hand. I treated hospitalized patients who had been diagnosed with diabetes within the past six months and their outpatient physician NEVER prescribed metformin to them. Instead, their doctors prescribed an expensive brand name diabetes pill like Starlix, which cost$102 per month—and is not even recommended as first line therapy for diabetes.
The authors say that in addition to being evidence-based, step therapy should have a reasonable exception process. There are a number of personal and clinical reasons why one medication would be favored over another and exceptions for those reasons should be made by the insurer or PBM.
At Compass, we help employees and their families go through the exception application process so they don’t fall through the cracks and not get the right medication. This administratively cumbersome process includes:
- Getting the appropriate documentation from the physician to the insurer or PBM
- Having it approved
- Having the new medication filled
Finally, the authors list Six Key Components of a Successful Step Therapy Program:
- Transparent policies on how the step therapy decisions were made
- Exception process for those patients who cannot tolerate certain medications or when the medication is ineffective
- Educate physicians on more rational prescribing practices
- Promote medication adherence
- Hold insurers accountable for the overall health of the patient
Compass has seen more and more of our clients implement step therapy programs over the last 18 months. As prescription medication costs rise faster than any other area of healthcare, I expect this trend to continue.
To learn more about Compass and our 2,000+ clients including Dillard’s, Brinker International and Atmos Energy, visit www.compassphs.com
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